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2012

ACADEMIC DOSSIER 1


ACADEMIC DOSSIER 2

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‫‏‬Content Augmentation and regeneration of the alveolar ridge ‫ ‏‬ase study 1: C ‫‏‬Case study 2: ‫‏‬Case study 3: ‫‏‬Case study 4:

Augmentation / Narrow Implants | Dr. Benjamin Retzkin Implantation with bone substitute | Dr. Benjamin Retzkin Restoring an area to proper form and function | Dr. Ara Nazarian, DDS Use of membrane and bone substitute | Dr. Benjamin Retzkin

7 8 10 12 17

‫‏‬Immediate implant placement

19

Case study 1: Immediate vs Delayed Single Implantation In the Anterior Maxilla: 2-Year Results | DMD. Themistoklis Th Mylonas Case study 2: Five years follow up of extraction & immediate implant placement of tooth with peri-apical pathosis | Samier Askar, DDS, and Tamer Abu Sada, DDS ±

20 25

‫‏‬Computerized implant planning

33

Case study 1: 7 Implants Maxilla | Dr. Korf Eitan Case study 2: 4 Implants Maxilla with Full Flap | Dr. Ziv Simon

34 37

Immediate loading

41

Case study 1: Sinus lift operation | Dr. Benjamin Retzkin Case study 2: mediate loading | Dr. Benjamin Retzkin

42 44

Screw-retained restoration on implant

45

Case study 1: Conservative vs invasive approach to implant supported restoration in the presence of impacted upper canine | Dr. Gil Rafalovitz Case study 2: Screw-Retained Implants | Dr. Nikolay Igorevich Vasil’yev & Dr. Alexei Petrovich Rashtanikov Case study 3: Screw-Retained restoration | Dr. Nikolay Igorevich Vasil’yev & Dr. Alexei Petrovich Rashtanikov ‫‏‬

46 47 56

Narrow implants

65

Case study 1: A clinical case demonstrating the use of narrow implants | Dr. Benjamin Retzkin Case study 2: Two narrow implants instead wide one | Dr. Gustavo Yatzkaier Case study 3: Narrow implants | Dr. Gustavo Yatzkaier Case study 4: Narrow implants | Dr. Benjamin Retzkin

66

‫‏‬Sinus lift operation

71

Case study 1: Sinus lift operation | Dr. Benjamin Retzkin Case study 2: Open sinus lift and two-stage implantation | Dr. Gustavo Yatzkaier Case study 3: Open sinus lift and implantation | Dr. Gustavo Yatzkaier

72 74 75

‫‏‬Temporary implants

79

Case study 1: Temporary implants | Dr. Benjamin Retzkin ‫‏‬Case study 2: Temporary implants | Dr. Benjamin Retzkin

80 82

68 69 70


Augmentation and regeneration of the alveolar ridge Regeneration of the alveolar ridge immediately after the extraction or in cases of a chronic defect has been a goal of clinicians and researchers. In the past, the importance of the regeneration was for prosthetic restoration of the area of the missing teeth before positioning the fixed partial denture. Now this procedure allows for installation of dental implants. Regeneration treatments are intended for increasing the bone volume to allow for better positioning of implants. The greater the volume of bone, the longer and wider the implants that may be installed are. In addition, a ridge of ideal dimensions allows for a correct eruption profile, which significantly improves aesthetics and facilitates the prosthetic work. Alveolar ridge augmentation words are diversified, from augmentation with an extraoral autogenic bone block to using bone substitutes that are not harvested using invasive techniques for augmenting local defects. The procedures for alveolar ridge augmentation demonstrate high success rates, which depend on many factors, such as the initial state of the ridge, the systemic status of the patient, the type and size of the procedure, the type of bone substitute and the skill of the operator. Despite the many factors that affect the success of the treatment, alveolar ridge augmentation operations are considered a common treatment among clinicians and researchers. 7


Case

1

Augmentation and regeneration of the alveolar ridge

Augmentation / Narrow Implants Dr. Benjamin Retzkin

A 28 year old female patient suffers from missing teeth 24, 25 (Figures 1, 2, 3). The lack of teeth caused narrowing of the ridge. It was decided to install two narrow implants of 3 mm diameter (Figures 6, 7) combined with thickening of the alveolar ridge using an allogenic bone graft along with allogenic bone granules (Figures 8,9). After 3 months, uncovering and temporary prosthetic restoration were performed (Figure 10). Figure 8

8

Figure 1

Figure 2

Figure 3

Figure 5

Figure 6

Figure 7

Figure 9

Figure 10

9


Case

2

Augmentation and regeneration of the alveolar ridge

Implantation with bone substitute Dr. Benjamin Retzkin

A 50 year old female patient, usually healthy, who complained of sensitivity and pain in tooth 17, lasting for some time. A clinical examination showed a buccal sinus tract (fistula). Second degree buccal furcation involvement. A PA x-ray image with a gutta percha tip (Figure 1) raised suspicion of a crack. The tooth was diagnosed as lost. Tooth 17 underwent non-traumatic extraction with splitting of the crown and roots.

The TCP granules are used to stop the migration of the epithelium (contact inhibition) and is absorbed spontaneously during the bone formation. After 6 months, a CT image and a clinical photograph were taken in preparation for installing the implant.

Figure 5 Figure 1

Figure 2

Figure 6

The implant was successfully installed with local sinus lifting.

The alveolar socket was filled using synthetic (alloplastic) TCP substance, a Gelfoam was laid and absorbable sutures were made.

Figure 7

Figure 3

10

Figure 8

Figure 4

11


Case

3

Augmentation and regeneration of the alveolar ridge

Restoring an area to proper form and function ‫‏‬Dr. Ara Nazarian

XX With a case study, Ara Nazarian illustrates the steps to replacement of a non-restorable tooth. Today, patients increasingly present with endodontically treated teeth that have failed for various reasons—fracture, recurrent caries, or periodontal problems. In the past, the common dental treatment would be to prepare the adjacent teeth for a three unit bridge. However, with implant therapy gaining more popularity among patients and providers, the request to have implant treatment has increased. It is my opinion that implant tooth replacement is the standard of care, and every dental provider needs to learn how to replace missing teeth using this modality at XX XX some level. This article discusses the steps taken to remove a non-restorable tooth, graft the area, and then replace it with an implant and corresponding abutment and crown restoration.

approximate location of the mucogingival junction to balance the beak. In other words, the beak grasps the tooth, while the bumper is the fulcrum to provide leverage and stability for the beak and wrist movement.

Restoring an area to proper form and fun

Using only wrist movement, a steady and gentle pressure was applied toward the buccal utilizing the Physics Forceps. Approximately within 30-60 seconds, the internal force or “creep” built up allowing the bone to slowly expand and the periodontal ligament to release. Once the With a case study, Ara Nazarian illustrates the steps to repl tooth disengaged from the socket, the tooth was removed with a maxillary forceps (Figure non-restorable tooth 2). Bone grafting material (Foundation™, J Morita) was placed into the socket (Figure 3) and oday, patients increasingly present sutured (Figure 4) to prevent any dislodgement. The surrounding cells and capillaries infiltrate with endodontically treated Foundation. As the extraction socket heals, is filled augmented bone. Foundation is teeth that ithave failedwith for new various reasons—fracture, recurrent caries, or small and medium sizes. shaped in “bullet” form for easy placement. It is available in both

T

Restoring an an area area to to Restoring proper form form and and function function proper

A 44-year-old woman presented with a severely broken down maxillary right first premolar (tooth No. 5) (Figure 1). The decay, already present in this tooth, had extended far below the free periodontal problems. In the past, the common dental was treatment would be(Figure to Approximately 12 weeks after healing, the area inspected 5) and a new radiograph gingival margin to the crest of bone and into the furcation. All risks, benefits, and alternatives prepare the adjacent teeth for a threewas taken to visualize the underlying There was with adequate were reviewed with the patient regarding treatment. The patient understood that the tooth would unitbone. bridge. However, implantwidth and height to place an 5 (AB Dental USA) dental implant that would replicate the premolar using a 3.75 mm need to be extracted; however, she did not want a bridge restoration for the final prosthesis. therapy gaining more popularity Witha acase casestudy, study,Ara AraNazarian Nazarianillustrates illustratesthe thesteps stepstotoreplacement replacementofofa a x 13 mmFigure With 1: Clinical view of non-restorable tooth among patients and providers, the implant. Instead, she insisted on having the tooth extracted, and the area grafted followed by implant non-restorabletooth tooth No. 5 non-restorable request to have implant treatment placement and restoration. The patient’s medical history was non-contributory. has increased. It is my opinion that oday, patients increasingly present

T Once the patient was fully anesthetized, the gingival tissue was slightly reflected with aT

12

oday, patients increasingly present with endodontically endodontically treated treated with teeththat thathave havefailed failedforforvarious various teeth mucoperiosteal elevator to separate the attachment. With the handles of the Physics®reasons—fracture, Forceps reasons—fracture, recurrent caries, recurrent caries, or or periodontal problems. past, problems. In In thethe past, thethe (Golden Dental Solutions) wide open, the beak was set into the depth of the lingual or periodontal palatal common dental treatment would common dental treatment would be be to to sulcus on solid root surface. A secure purchase point on solid root surface was criticalprepare to prepare adjacent teeth a threethethe adjacent teeth forfor a threesuccessfully rolling out the tooth. When necessary, it is not uncommon to create a small trench unit bridge.However, However,with withimplant implant unit bridge. therapygaining gainingmore morepopularity popularity therapy with a small, flame-shaped diamond bur to engage the beak more securely on solid root Figure 1: view of non-restorable tooth 1: Clinical view of view non-restorable amongpatients patientsand andproviders, providers,thethe Figure Figure 1:Clinical Clinical of non-tooth among No. 5 5 surface. Once the beak was placed, the bumper was positioned on the alveolar ridge atrequest the requestto tohave haveimplant implanttreatment treatment No. restorable tooth No. 5 increased. opinion that hashas increased. It It is is mymy opinion that implanttooth toothreplacement replacementis isthethe implant standardof ofcare, care,and andevery everydental dental standard provider needs learn how replace provider needs to to learn how to to replace missing teeth using modality missing teeth using thisthis modality at at

implant tooth replacement is the standard of care, and every dental provider needs to learn how to replace missing teeth using this modality at some level. This article discusses the steps taken to remove a non-restorable tooth, graft the area, and then replace it with an implant and corresponding Figure 2: Extracted tooth Figure 2: Extracted tooth abutment and crowntooth restoration. Figure 2: 2 Extracted A 44-year-old woman presented with a severely broken down maxillary right first premolar (tooth No. 5) (Figure 1). The decay, already present in this tooth, had extended far below the free gingival margin to the crest

Figure 3: Placement of graftingofmaterial Figure 3: Placement grafting

Figure 2: Extra

Figure 4: Graf

material

13


Restoring an area areato to > Restoring an Restoring an area toand proper form and function proper form function proper form and function Augmentation and regeneration of the alveolar ridge

‫‏‬Dr. Ara Nazarian With a case study, Ara Nazarian illustrates the steps to replacement of a With a case study, Ara Nazarian illustrates the steps to replacement of a non-restorable tooth non-restorable tooth

T T rea to

oday, patients increasingly present

patients increasingly Aoday, 2.0 pilot drill waspresent placed withmm endodontically treated into the site and advanced to a depth of 15 mm measuring from with endodontically treated teeth that have failed for various the that tissue surface. This additional 2 mm was the same depth of the tissue height to bone. In teeth have failed for caries, variousor reasons—fracture, recurrent other words, 13 mm for theorosteotomy in bone and 2 mm for tissue thickness was created to reasons—fracture, recurrent caries, periodontal problems. In the past, the periodontal problems. In the past, the A parallel pin gauge was placed in the site of the osteotomy, and place adental 13 mm long implant. common treatment would be to common dental treatment would be to an x-ray toteeth check angulations of the pin between the adjacent teeth within the maxilla. prepare the taken adjacent for the a threeprepare the adjacent teeth for a threeunit bridge. However, with implant Using a rotary tissue bridge. However, withpunch, implant stepsunit to replacement a a 4 mm outline was created over the initial osteotomy and the tissue therapy gaining with morea of popularity plug removed curette. drills sequentially utilized to increase therapy gaining more popularity Intermediate Figure 1: Clinical view ofwere non-restorable tooth Figure 2: Extracted tooth the size among patients and providers, the Figure 1: Clinical view of non-restorable tooth Figure 2: Extracted tooth among and providers, thecompleted, No. 5 of thepatients final osteotomy. Once a 3.75 mm x 13 mm 5 (AB Dental USA) conical groovy No. 5 request to have implant treatment request to have implant treatment implant (Figure placed has increased. It is 6) mywas opinion thatin the osteotomy using the enclosed Clip Carrier (AB Dental USA) has increased. It is my opinion that implant tooth replacement is the until increased torque was necessary. The ratchet wrench was then connected to the driver implant tooth replacement is the standard of care, and every dental standard of and care,the andimplant every dental adapter torqued to final depth reaching a torque level of 65 Ncm (Figure 7). providerneeds needstotolearn learnhow howtotoreplace replace provider A 5 mm healing abutment, included with the implant, was handtightened to the implant missing teeth using this modality missing teeth using this modality at at (Figure A article postoperative radiograph was made of the implant and the healing abutment. The some level.8). This articlediscusses discussesthe the some level. This steps taken to remove a non-restorable implant evaluated clinically after one week. The patient stated she had no post-operative steps taken towas remove a non-restorable tooth, graftthe thearea, area, andthen thenreplace replace tooth, graft and discomfort or swelling.

nd function

he

e tooth

al

with2: implant andcorresponding corresponding Extracted tooth ititFigure with anan implant and abutment and crown restoration. abutment and crown restoration. 44-year-oldwoman womanpresented presented AA44-year-old with a severely broken down maxillary with a severely broken down maxillary right first premolar (tooth No.5)5) right first premolar (tooth No. (Figure 1). The decay, already present (Figure 1). The decay, already present in this tooth, had extended far below in this tooth, had extended far below the free gingival margin to the crest the free gingival margin to the crest of bone and into the furcation. of bone and into the furcation. AllAll risks,benefits, benefits,and andalternatives alternativeswere were risks, reviewedwith withthe thepatient patientregarding regarding reviewed treatment. Thepatient patient understood that treatment. understood Figure 4:The Graft material securedthat Figure 4: Graft material secured with sutures the tooth wouldneed needtotobebeextracted; extracted; the tooth would with sutures however, however,she shedid didnot notwant wanta abridge bridge restoration for the final prosthesis. restoration for the final prosthesis. 14 Instead, Instead,she sheinsisted insistedononhaving havingthethe tooth toothextracted, extracted,and andthe thearea areagrafted grafted

Figure 3: Placement of grafting material Figure 3: Placement of grafting material

Figure 5: Healed ridge

Figure 5: Healed ridge Figure 5: Healed ridge

Figure 4: Graft material secured sutures Figure 4: Graft material secured with with sutures

Figure 6: 5 AB Dental USA implant

Figure AB Dental implant Figure 6: I56:ABI5Dental USA USA implant

to to release. Once the the tooth to to create a small trench with a small, ligament release. Once tooth create a small trench with a small, ligament the the flame-shaped diamond burbur to to engage disengagedfrom fromthe thesocket, socket, flame-shaped diamond engage disengaged thethebeak more securely onon solid root waswas removed withwith a maxillary beak more securely solid root tooth tooth removed a maxillary surface. waswas placed, Bone grafting surface.Once Oncethethebeak beak placed, forceps forceps(Figure (Figure2). 2). Bone grafting

When the patient returned 3-months later, the healing abutment was removed and a SmartPeg™ (Osstell®) was attached to the implant to confirm osseointegration. Using the hand-held probe of the Osstell ISQ® unit, the SmartPeg was stimulated magnetically, without actually being connected to it–or even touching it. Positioning it from buccal to lingual and mesial to distal, readings of 82/84 were recorded on the unit. An ISQ (Implant Stability Quotient) is a measurement scale for use with the RFA (Resonance Frequency Analysis) method of determining implant stability. It’s a mapping of resonance frequencies (kHz), presented as a clinically useful scale of 1-100 ISQ. The higher the ISQ value, the more stable the implant. Utilizing a Clip Impression Transfer (AB Dental USA), an impression was taken of the implant with no affixing screw (Figure 9). Suitable for closed tray method, there is no need to remove it or to insert the transfer as it remains in the impression throughout the process. A heavy and light bodied polyvinyl siloxane impression material (Take One® Advanced™, Kerr) was used in a fullarch impression tray. Once the impression material was set, it was removed from the mouth, picking-up the Clip Impression Transfer) and sent to the lab for custom abutment and crown fabrication (Figure 10). When the patient returned for the seating appointment, the Inclusive® (Glidewell) titanium abutment (Figure 11) with corresponding BruxZir® (Glidewell Dental Lab) crown was placed, and another x-ray was taken to verify an accurate fit. Since there were no open margins, and the contacts and occlusion were good, the crown restoration was seated using Maxcem Elite™ (Kerr) cement (Figure 12). Once the cement reached its gel stage, it was quickly cleaned off and any excess removed. The patient was very pleased with the end result and was pleased to have all the services (extraction, grafting, dental implant, abutment and restoration) at one location. Today, patients like to get all their services under one roof. They know, trust, and feel comfortable with their 15


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Augmentation and regeneration of the alveolar ridge

Case

4

Restoring an area to proper form and function ‫‏‬Dr. Ara Nazarian

Use of membrane and bone substitute Dr. Benjamin Retzkin

XX XX XX XX

dental provider and usually prefer him/her to perform all their dental procedures necessary to XX XX reach optimum dental health.

Figure Figure 7: Dental Dental implant implant placed placed Figure Dental implant placed 7:7:7: Dental implant placed Figure Dental implant placed Figure 7: Dental Figure 7: Dental implantimplant placed placed

Augmentation and regeneration of the alveolar ridge

Figure Figure 8:8:8: Healing Healing cap cap Figure 8: Healing cap Figure Healing cap Figure Healing cap

Figure 8: Healing Figure 8: Healing cap cap

Figure Figure 9:Figure 9: Clip impression impression transfer transfer 9: Clip impression transfer Figure 9:Clip impression transfer Figure 9:Clip Clip impression transfer

Figure 9: Clip impression Figure 9: Clip impression transfer transfer

A 75 year old female patient, in a balanced systemic condition. Tooth 45 had recently been extracted. Tooth 46 had been replaced by an old implant without an internal or external hexagon. Upon opening the site and installing the implant, a deficiency of buccal hard tissue after the extraction was observed.

Figure 1

Figure 2

An implant was installed with Biofill-S bone substitute grafting and an absorbing membrane (collagen) was laid. Figure Figure 10:10: FullFull arch arch impression impression

Figure 10:Full Fullarch arch impression Figure 10: impression Figure 10: Full arch impression Figure 10:Full Fullarch arch impression Figure 10: impression

place placeananimplant implantthat thatwould wouldreplicate replicate place an implant that would replicate place an implant that would replicate the the premolar premolar using using a a 3.75 3.75 mm mmx x placean animplant implant that that would would replicate place replicate the premolar using a 3.75 mm the premolar using a 3.75 mm xxx 13 13 mm mm I5 I5 (AB (AB Dental Dental USA) USA) dental dental the premolar premolar using using aa 3.75 3.75 mm the mm x 13 mm (AB Dental USA) dental 13 mm I5I5 (AB Dental USA) dental implant. implant. 13 mm I5 (AB Dental USA) dental 13 mm I5 (AB Dental USA) dental implant. implant. A A2.0 2.0mm mmpilot pilotdrill drillwas wasplaced placed implant. implant. 2.0 mm pilot drill was placed AA 2.0 mm pilot drill was into into the the site site and and advanced advanced totoaplaced adepth depth A 2.0 mm pilot drill was placed A 2.0 mm pilot drill was placed of of 15 15 mm mm measuring measuring from from the the tissue tissue into the site and advanced to a depth into the site and advanced to a depth intothe thesite site and and advanced advanced to to aa depth into depth surface. surface. This This additional additional 2 2 mm mm was was 15 mm measuring from the tissue ofof 15 mm measuring from the tissue of15 15mm mm measuring measuring from from the the tissue of tissue the thesame same depth depth ofofthe thetissue tissue height height surface. This additional 2 mm was surface. This additional 2 mm was surface. This additional 2 mm was surface. This additional 2 13mm was totobone. bone. In Inother otherwords, words, 13 mm mm for for the same depth the tissue height the the same same depth depth ofof of the the tissue tissue height height the the osteotomy osteotomy in in bone bone and and 2 2 mm mm for for sameInIn depth ofwords, the tissue height 16 the bone. other words, 13 mm for toto bone. other 13 mm for to bone. In otherwas words, 13tomm for tissue tissue thickness thickness was created created to place place to bone. In other words, 13 mm for the osteotomy bone and mm for the osteotomy inin bone 222mm for the osteotomy inimplant. boneand and mmpin for a a13 13thickness mm mmlong long implant. A Aparallel parallel pin the osteotomy in bone and 2totomm for tissue thickness was created place tissue was created place

Figure Figure 11:11: Inclusive Inclusive abutment abutment placed placed

Figure Figure 12:12: BruxZir BruxZir crown crown placed placed

Figure 11:Inclusive Inclusive abutment placed Figure 12:12: BruxZir crownplaced placed placed Figure 11: abutment placed Figure 12: crown Figure Inclusive abutment Figure BruxZir crown Figure 11: Inclusive abutment placed Figure 12:BruxZir BruxZir crown placed Figure 11:11: Inclusive abutment placed Figure 12: BruxZir crown placed ®® swelling. swelling. seating seating appointment, appointment, the theInclusive Inclusive placed ®® swelling. seating appointment, the Inclusive seating appointment, the Inclusive swelling. ® ® (Glidewell) (Glidewell) titanium titanium abutment abutment (Figure (Figure When When the the patient patient returned returned seating the the Inclusive swelling. seatingappointment, appointment, Inclusive swelling. ® ® (Glidewell) titanium abutment (Figure When the patient returned (Glidewell) titanium abutment (Figure When the patient returned 11) 11) with with corresponding corresponding BruxZir BruxZir 3-months 3-months later, later, the the healing healing abutment abutment (Glidewell) titanium abutment (Figure When (Glidewell) titanium abutment (Figure When the the patient patient returned returned ®® ™™ 11) with with corresponding BruxZir 3-months later, the healing abutment 11) corresponding 3-months later, the abutment was was removed removed and andhealing a a SmartPeg SmartPeg (Glidewell (Glidewell Dental Dental Lab) Lab)crown crownBruxZir was was ® ® 11) with corresponding BruxZir 3-months later, the healing abutment 11) with corresponding BruxZir 3-months later, the healing abutment ™™ ® ® was removed and a SmartPeg (Glidewell Dental Lab) crown was (Glidewell Dental Lab) crown was was removed and a SmartPeg (Osstell (Osstellremoved ) was ) wasattached attached totothe theSmartPeg implant implant ™placed, placed, and andanother another x-ray x-ray was wastaken takentotowas ™ (Glidewell Dental Lab) crown was and (Glidewell Dental Lab) crown was was ®removed and toatoathe SmartPeg ® placed, andanother another x-ray was takentoto to (Osstell was attached the implant )®))osseointegration. was attached implant (Osstell placed, and x-ray was taken to toconfirm confirm osseointegration. Using Using the the verify verify ananaccurate accurate fit.fit.Since Since there there were were ® (Osstell placed, and another x-ray was taken was attached to the implant (Osstell ) was attached to the implant placed, and another x-ray was taken ®® hand-held hand-held probe probe ofofthe theOsstell Osstell ISQ ISQ open open margins, margins, and and thecontacts contacts verify an accurate fit.the Since therewere were to confirm osseointegration. Using thenono toto confirm osseointegration. Using the verify an accurate fit. Since there verify an accurate fit. Since there were to confirm osseointegration. Using the to confirm osseointegration. Using the verify an accurate fit. Since there unit, unit,the theSmartPeg SmartPeg was wasOsstell stimulated stimulated and occlusion occlusion were weregood, good, the crown crown no open margins, margins, andthe the contactswere hand-held probe the Osstell ISQ®®®and hand-held probe ofof the ISQ no open and contacts hand-held probe ofof the Osstell ISQ ® no open margins, and the contacts hand-held probe the Osstell ISQ no open margins, and the contacts magnetically, magnetically, without withoutactually actually being being restoration restoration was wasseated seated using Maxcem Maxcem and occlusion occlusion wereusing good, the crown crown unit, the SmartPeg was stimulated unit, and were good, the unit, the the SmartPeg SmartPeg was was stimulated stimulated and occlusion were good, the crown ™ and ™ unit, the SmartPeg was stimulated occlusion were good, the crown connected connectedtotoit–or it–or even eventouching touchingbeing it.it. Elite Elite (Kerr) (Kerr)cement cement (Figure (Figure 12). 12).Once Once restoration wasseated seated using Maxcem magnetically, without actually magnetically, was using Maxcem magnetically, without without actually actually being being restoration restoration was seated using Maxcem ™ ™ Positioning Positioning it it from from buccal buccal to to lingual lingual the the cement cement reached reached its its gel gel stage, stage, it it was was magnetically, without actually restoration was seated Maxcem 5 Elite connected it–or even touchingbeing it. Elite (Kerr)cement cement (Figureusing 12).Once Once (Figure 12). connected toto even touching it.it. ™(Kerr) (Kerr) cement (Figure 12). Once connected to it–or it–or even touching Elite ™ and and mesial mesialitto distal, distal, readings readings ofof quickly cleaned cleaned offoff and and any any excess excess (Kerr) cement (Figure 12). Once connected toto it–or even touching it.quickly Elite Positioning it from buccal to lingual the cement reached its gel stage, it was the cement reached its gel stage, it was Positioning from buccal to lingual the cement reached its gel stage, it was Positioning it from on buccal to lingual 82/84 82/84 were wererecorded recorded on the the unit. unit. An removed. the cement reached its any gel it was Positioning itto from buccal to An lingual and mesial distal, readings quickly cleaned off and and anystage, excess quickly cleaned off excess and mesial to distal, readings ofofremoved.

Figure 5: Nylon sutures

Figure 3

Figure 4

Figure 6: Normal healing

Figure 7: Final prosthetic restoration

17


I‍ �‏mmediate implant placement This procedure consists of the placement of an implant in an extraction socket immediately after the dental extraction. Implants can be placed at the time of extraction with extremely high success rates as long as esthetic considerations are not a major factor. Immediate implant placement should not be an option with Infected sockets. The portion of the implant will not integrate unless the gap is filled with a bone graft and protected by a regenerative membrane (when the gap exceeds 2 mm). This is done in order to achieve primary stability and produce high survival rate.

19


Case

1

‫‏‬Immediate implant placement

Immediate vs Delayed Single Implantation In the Anterior Maxilla: 2-Year Results DMD. Themistoklis Th Mylonas

Presented at the 20th Annual Scientific Meeting of the European Association of Osseointegration, 3-15 October 2011, Athens, Greece. Abstract Long-term studies have reported almost perfect survival rates for single tooth implant restorations. In the anterior zone, the success of such a therapy is determined by the aesthetic outcome. Is the immediate implantation a treatment strategy for an optimal outcome? The objective of this clinical study was to evaluate the aesthetic outcome following immediate and delayed implantation treatment in the anterior maxilla. Material and Methods: 15 patients with immediate implantations and 15 patients with delayed implantations to restore the anterior maxilla were selected. Prerequisites for immediate implantation were the appropriate bone volume, the absence of acute inflammation and the intact socket walls. Both immediate and delayed implantations performed with a minimal flap procedure and were provisionally restored using a conventional single tooth denture. The aesthetic result was assessed after 2 years using the pink and the white aesthetic score (PES/WES). The subjective appreciation was also recorded. Results: None of the implants failed. The bone level in the second group appeared to be more stable than in the first. The aesthetic failures were high for both groups (‹25%) but a high satisfaction score (›75%) was reported. Immediate implantation is a viable treatment option but an aesthetically perfect outcome is determined by a number of factors.

20

Background and Aim After tooth extraction occurs a great bone loss. Consequently, the surrounding soft-tissue can collapse causing unpredictable aesthetic problems. In order to treat this soft tissue recession a number of surgical procedures with uncertain results will be needed. The immediate implantation minimizes the surgical time and guides the implantation, shortens the overall treatment time and reduces the surgical interventions expressing the patient’ s choise. The delayed implantation presents a lower risk for implant failure, less contraindications, ease to achieve implant stability and it facilitates the monitoring of the implant position. The objective of this clinical study was to evaluate the aesthetic outcome following immediate and delayed implantation treatment in the anterior maxilla. Methods and Materials Material and Methods: 15 patients with immediate implantations and 15 patients with delayed implantations to restore the anterior maxilla were selected. Prerequisites for immediate implantation were the appropriate bone volume, the absence of acute inflammation and the intact socket walls. Both immediate and delayed implantations were performed with a minimal flap procedure and were provisionally restored using a conventional single tooth denture. The aesthetic result was assessed after 2 years using the pink and the white aesthetic score (PES/ WES).

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‫‏‬Immediate implant placement

Immediate vs Delayed Single Implantation In the Anterior Maxilla: 2-Year Results DMD. Themistoklis Th Mylonas PES/IIP

1. Mesial Papilla 2. Distal Papilla 3. Curvature of facial mucosa 4. Level of facial mucosa 5. Root convexity /Soft Tissue Colorand Texture

2 2 2 1

1. Tooth form 2. Tooth volume 3. Color 4. Surface 5. Translucency

2 1 1 2 1

2

Mesial Distal Curvature Level facial Root conv S/T Tooth Pap Pap facial Mucosa Mucosa color-texture form

Volume Color

Surface Translucency texture

Mean

1,5

1,47

1,40

1,33

1,67

1,67

1,80

1,60

1,87

1,60

SD

0,52

0,52

0,51

0,49

0,49

0,49

0,41

0,51

0,35

0,51

Min

1

1

1

1

1

1

1

1

1

1

Max

2

2

2

2

2

2

2

2

2

2

PES/CIP Mean

1,27

SD

0,46

Min

The subjective appreciation was also recorded. The first question was about the overall treatment protocol, the second was about the patient's expectations and the third addressed the satisfaction only from an esthetic point of view.

WES/IIP

Max

2

WES/CIP

1,33

1,33

1,80

1,47

1,33

1,73

1,60

1,47

0,46

0,49

0,49

0,41

0,52

0,49

0,46

0,51

0,52

1

1

1

1

1

1

1

1

1

2

2

2

2

2

2

2

2

2

PES=Pink esthetic score, WES=White esthetic score, IIP=Immediate implant placement, CIP= Conventional implant placement

Results The 30 implants fulfilled the success criteria. The mean total PES scores for the immediate implantation were 7.65 and for the delayed 6.98. The mean total WES was 7.8 and 7.55 respectively. The first question about the treatment protocol was answered positively by 86% and 76%. The second question about the treatment outcome was answered positively by 86% for both groups. The positive results about the aesthetic satisfaction were 86% and 80%.

22

Conclusions This study demonstrated that immediate single-tooth implant replacement is not only a successful and predictable treatment modality with perfect survival results but also induces a positive and reliable aesthetic and psychological outcome. Regarding the reflection to the daily practice, many extraction sites are needed to be filled with a grafting material or to be conditioned with connective tissue grafts. These two advanced procedures could affect the predictability of this treatment. Careful case selection, excluding contraindications and clinical experience is mandatory for positive results. On the other hand, 23


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‫‏‬Immediate implant placement

Immediate vs Delayed Single Implantation In the Anterior Maxilla: 2-Year Results

Case

2

DMD. Themistoklis Th Mylonas the reproduction of the anatomical characteristics via implant crown is of great importance. The abutment – crown complex can lead to a natural integration or to a failure. From this point of view, the WES highlights the appearance of the crown above the peri-implant mucosal margin. The submucosa portion, which relocates and determines the final location and even the thickness of the soft tissue, is not considered. The immediate implantation would result in comparable –or even better- treatment outcomes than conventional implant protocols under some considerations. References 1. Henriksson K, Jemt T. Measurements of soft tissue volume in association with singleimplant restorations: a 1 year comparative study after abutment connection surgery. Clin Implant Dent Relat Res 2004; 6(4): 181-9 2. Hartmann H-J and Steup A. Implant-supported anterior tooth restoration. Keio J Med 2006; 55(1):23-8 3. Belser et al. Outcome Evaluation of Early Placed Maxillary Anterior Single-Tooth Implants Using Objective Esthetic Criteria: A Cross-Sectional, Retrospective Study in 45 Patients With a 2- to 4-Year Follow-up Using Pink and White Esthwtic Scores. J Periodontol 2009;80:140151 4. Den Hartog L et al. Treatment outcome of immediate, early and conventional single-tooth implants in the aesthetic zone: a systematic review to survival, bone level, soft tissue, aesthetics and patient satisfaction. J Clin Periodontol 2008; 35: 1073-1086 5. Cho et al. Esthetic evaluation of maxillary single-tooth implants in the esthetic zone. J Periodontal Implant Sci 2010; 40:188-193.

24

‫‏‬Immediate implant placement

5 years follow up of extraction & immediate implantation of tooth with peri-apical pathosis Samier Askar, DDS,* and Tamer Abu Sada, DDS ±

* Post graduate stidues in Oral pathology, Completence University, Madrid, Spain, Private practice, Ramallah, Palestinian Authority. ± Private practice, Ramallah, Palestinian Authority.

Abstract This case report is presented to enable clinicians to do immediate implantation & loading even if there’s peri-apical pathosis under the tooth in the site of future implant position. A clinical case is presented to describe the technique. Pre-medicate the patient with Anti Biotics,Gentle Extraction of the tooth, all the lesion must be cleaned very well until sound bone felt all over the defect, implant selection is very important( Wide threating, suitable diameter and length). Primary stability achievement also very important for immediate loading(over 35 Ncm) and finally place the prosthetic contact free. Key words: Immediate Implantation, Immediate loading, Implant selection, primary stability, contact free. Introduction Dental Implants have become the first option in treating missing teeth. Immediate Implant placement and loading have become important for patients’ comfort. It reduces surgical procedures and bone loss. One of the requirements of immediate implant placement is implant primary stability. Peri- apical pathosis of the replaceable tooth impairments the probability of primary stability. This case report express the method for immediate placement of dental implant after extraction of infected tooth with peri-apical pathosis.

25


DentalImplants Implantshave havebecome becomethe thefirst firstoption optioninintreating treatingmissing missingteeth. teeth.Immediate ImmediateImplant Implant Dental placement and loading have become important patients’ comfort. It reduces surgical placement and loading have become important forfor patients’ comfort. reduces surgical placement and loading have become important for patients’ comfort. ItItreduces surgical Figure 1. Pre-Op X-Rays Figure 2. Socket debridFigure 3. Implant placem procedures and bone loss. procedures and bone loss. procedures and bone loss. ‫‏‬Immediate implant placement of patient demonstrated a 2. ement after gentle extrNcm force with torque which Figure 1. Pre-Op X-Rays debrid3. Implant placement 35 35 Figure 1. Pre-Op X-RaysFigure FigureSocket 2. Socket debrid-Figure Figure 3. Implant placement with One of the requirements of immediate implant placement is implant primary stability. Oneof ofthe therequirements requirementsofofimmediate immediate implant placement implant primary stability. One implant placement isisimplant primary stability. > Failed with broken action. ble immediate loading. demonstrated a ement after gentle extr-extr-NcmNcm forceforce torque which indicate possiof RCT patient demonstrated a ement after gentle torque which indicate possiPeriapical pathosis of replaceable tooth impairments the probability of primary stability. of patient Periapical thethe replaceable tooth impairments theimmediate probability primary stability. Periapical pathosis ofofthe replaceable tooth impairments the probability ofofprimary stability. 5pathosis years follow up of extraction & Failed RCTRCT with broken action. ble immediate loading. instrument and large periFailed with broken action. ble immediate loading. This case report express method immediate placement of dental implant after extractioninstrument and large periThis case report express thethe method forfor immediate placement dental implant after extraction This case report express the method for immediate ofofdental implant after extraction implantation of tooth withplacement peri-apical pathosis andtooth large periapicalinstrument lesion in #10 of infected tooth with periapical pathosis. infected tooth with periapical pathosis. ofofinfected tooth with periapical pathosis. apical lesion in tooth #10 #10 apical lesion in tooth ‫‏‬Samier Askar, DDS,* and Tamer Abu Sada, DDS ±

Case presentation Case presentation Case presentation Case presentation

(22)associated with pain. (22)associated with pain.pain. (22)associated with

A 46-years female patient presented with with a with chief ofcomplaint a pain inof tooth #10(22). A 46-years female patient presented with a chief a pain in tooth #10(22). 46-years female patient presented achief chief complaint ofaof apain pain tooth #10(22). AA46-years female patient presented acomplaint complaint inintooth #10(22). Radiographic Examination revealed a broken instrument inside the canal with large Peri-apical Radiographic Examination revealed a broken instrument inside canal with large Peri-apical Radiographic Examination revealed broken instrument inside thethe canal with large Peri-apical Radiographic Examination revealed aabroken instrument inside the canal with large Peri-apical pathosis (Figure 1). The patient refused temporary restoration and asked for final one. pathosis(Figure The patient refused temporary restoration and asked final one. pathosis(Figure 1).1). The patient refused temporary restoration and asked forfor final one. pathosis(Figure 1). The patient refused temporary restoration and asked for final one. Extraction and Immediate Implantation were suggested. The patient accepted the treatment Extraction and Immediate Implantation were suggested. The patient accepted treatment plan. Extraction and Immediate Implantation were suggested. The patient accepted thethe treatment plan. Extraction and Immediate Implantation were suggested. The patient accepted the treatment plan. plan. Inform consent was signed after detailed explanation of treatment plan. Inform consent was signed after detailed explanation ofofthe treatment plan. Inform consent was signed after detailed explanation thethe treatment plan. Figure 4. Implant in itsinsiteits Figure 5. Angulated abutment 6. days later abutment Figure 4: Implant its proper Figure 6. 33days abutment Figure 5. Angulated abutment Figure 4. inImplant Figure 5. Angulated abutment Figure Figure 6. 3later days later abutment Inform consent was signed after detailed explanation of the treatment plan. placed and impression taken checked. site. site. checked. placed and impression taken. Tooth #10 was scheduled extraction, Patients were instructed in of chlorhexidine proper proper checked. placed and impression taken. Tooth #10 was scheduled for extraction, Patients were instructed ininthe use ofofchlorhexidine Tooth #10 was scheduled forfor extraction, Patients were instructed thethe useuse chlorhexidine Tooth #10 was scheduled for extraction, Patients were instructed in the use of chlorhexidine digluconate chemical control of plaque, which commenced 3 days prior to surgery andFigure 4. Implant in its Figure 5. Angulated abutment Figure 6. 3 days la digluconate the chemical control ofofplaque, which commenced 3 3surgery days prior totosurgery and digluconate forfor thethe chemical control plaque, which commenced days prior surgery and digluconatefor for the chemical control of plaque, which commenced 3 days prior to and continued 10 days postoperative. Antibiotic prophylaxis involved daily administration The toothsite. was extracted and the root was measured. A gentle avulsion technique was used toand Page 2 2 checked. placed impres continued 10 days postoperative. Antibiotic prophylaxis daily ofof2of continued for 10days days postoperative. Antibiotic prophylaxis involved daily 2 2proper Page continuedfor forfor 10 postoperative. Antibiotic prophylaxis involved dailyinvolved administration of administration 2 administration minimize trauma to the surrounding tissues, and the socket was thoroughly debrided (figure 2). grams of amoxicillin & clavulanic acid, 2surgery hours before surgery and 5 days after. grams amoxicillin && clavulanic acid, beginning 2beginning hours before and for 5 days after. grams ofofofamoxicillin acid, beginning 22hours before surgery and for after. grams amoxicillin &clavulanic clavulanic acid, beginning hours before surgery and for5for 5days days after. Osteotomies were prepared with the aid of a surgical template and implants with micro-textured On the day of surgery, the patient was anesthetized via local via infiltration in theinfiltration maxilla. ininthe the day of surgery, the patient was anesthetized local in maxilla On the day of the patient was anesthetized local infiltration maxilla OnOn the day ofsurgery, surgery, the patient was anesthetized viavia local infiltration thethe maxilla surfaces (Conical groovy implant,AB-Dental,Ashdod-Israel) were placed in accordance with the manufacturer’s protocol, 16 mm implant was inserted to achieve 5 mm bone anchorage in sound bone above the cyst cavity (Figure 3). Implant inserted into its proper position at the middle of the space slightly palataly with high preservati- on of the buccal plate, 1 mm below the bone crest to preserve the aesthetic zone and bone height). Bone substitute (Crused cancellous bone, Pacific Coast Tissue Bank,Los Angeles,CA) inserted to fill the gap between implant and the socket wall (Figure 4). Figure 2:2. Socket debridement after Figure 3: Implant placement withplacement Figure1. 1: X-Rays ofX-Rays patient Figure 1. Pre-Op Figure 2. Socket debridFigure 3. Implant with Figure Pre-Op X-Rays Figure debridFigure 3.3.Implant placement with 353535 Figure 1.Pre-Op Pre-Op X-Rays Figure 2.Socket Socket debridFigure Implant placement with gentle extraction 35 Ncm force torque which indicate demonstrated a Failed RCT with of patient demonstrated ement after gentle extr- Ncm Ncm force torque which indicate possiofofpatient demonstrated aa aement after gentle extrforce torque which indicate possipatient demonstrated ement after gentle extrNcm force torque possible immediate loading which indicate possibroken. instrument and large Failed RCT broken action. immediate loading. Failed RCT with broken action. ble immediate loading. periapical lesion inwith tooth #10 (22) Failed RCT with broken action. bleble immediate loading. associated with pain instrument and large periinstrument and large periinstrument and large periapical lesion in tooth apical lesion in tooth #10#10 26apical lesion in tooth #10 (22)associated with pain. (22)associated with pain. (22)associated with pain.

27


Angeles,CA) inserted to fill the gap between implant and the socket wall(Figure 4).

y implant,AB-Dental,Ashdod-Israel) surfaces (Conical groovy implant,AB-Dental,Ashdod-Israel) were placed in accordance with were theplaced in accordance with the , 16 mm manufacturer’s implant was protocol, inserted 16 to achieve mm implant 5 mmwas bone inserted anchorage to achieve in sound 5 mm bone anchorage in sound ‫‏‬Immediate implant placement ity(Figure bone above 3). > the cyst cavity(Figure 3). proper Implant position inserted at 5 theyears into middits le proper of theposition space at the middpalataly le of with the& high space slightly palataly with high follow upslightly of extraction immediate and the root was measured. A gentle avulsion technique was used to cal plate, preservati1 mm on below of the thebuccal bone crest plate,to 1 preserve mm below the the aesthetic bone crest zonetoand preserve the aesthetic zone and implantation of tooth with peri-apical surrounding tissues, and the socket was thoroughly debrided (figure 2). pathosis titute(Crused bone height). cancellous Bone substitute(Crused bone, Pacific Coast cancellous Tissue Bank,Los bone, Pacific Coast Tissue Bank,Los red with the aid of‫‏‬Saamier surgical template and implants with micro-textured Askar, DDS,* and Tamer Abu Sada, DDS ±4 Figure 7. . next day crown placed fill the Angeles,CA) gap between inserted implant to fill andthe thegap socket between wall(Figure implant4).and theafter socket wall(FigureFigure 4). 8. 3 years after. y implant,AB-Dental,Ashdod-Israel)days were placedplacement. in accordance with the of implant implant placement , 16 mm implant was inserted to achieve 5 mm bone anchorage in sound ity(Figure 3). proper position at the midd- le of the space slightly palataly with high ccal plate, 1 mm below the bone crest to preserve the aesthetic zone and titute(Crused cancellous bone, Pacific Coast Tissue Bank,Los fill the gap between implant and the socket wall(Figure 4).

Figure 8: 33years afterafter. implant wn placed Figureafter 7. . 4next day crown placed Figure after 8. 4years Figure 7: placement ent. days of implant next placement. implant placement day crown

Figure 9. OPT years later. Figure 9:8. OPT years later Figure 333years after.

Figure 5 years later. Figure 10. 510. years later.10.late Figure 5 years

implant placement

Askar et al

Askar et al

Figure 11. Periapical X-ray Figure of11. Periapical X-ray after 5 after 5 years implantation of implantation years of implantation Figure 11. Periapical X-ray after 5 years

An angulated abutment checked to ensure crown position on implant (Figure 5), after that placed after 4 suturing was done. Conclusion days of implant 3 days later after implant placement the patient recalled for sutures removal and angulated placement ImmediateConclusion Implant and loading can be done in compromised bone as this presented case (Failed abutment was put over the implant. Impression was taken for final crown (Figure 6). Immediate Implant and loading can be done in compromised bone as this presented case (Failed RCT withperiapical large periapical pathosis). RCT with large pathosis). One day after, crown was ready and delivered to the patient (Figure 7). Curettage, cleaning of the whole area up to good bone quality and primary stability are the main necessities for success. After 3 years of Implant placement the patient returned, she showed a little cervicalCurettage, porcelaincleaning of the whole area up to good bone quality and primary stability are the main Conclusion wn placed after 4 Figure 8. 3 years after. necessities for success. crack but the patient didn’t want to replace the crown(Figure 8). Follow–up x-ray reveal bone in loading Immediate Implant and can be done in compromised bone as this presented case (Failed Credits and Special Appreciation the periapical pathosis location (figure 9). RCT with large periapical pathosis). ent. implant placement An angulated abutment checked to ensure crown position on implant (Figure 5), after that cleaningDrof the wholeProsthodontist, area up to good bone quality and primary stability are the main Zeev Ormianer, DICOI 5 years later the patient returned for annual check-up (Figure 10). No bone lossCurettage, was visible suturing was done. Credits andDirector, Special Appreciation Oral Implants Prosthodontic Clinic necessities for success. Department of Oral Rehabilitation (Figure 3 days later after implant placement the 11). patient recalled for sutures removal and angulated School of Dental Medicine

Figure 9. OPT 3 years later. Figure 9. OPT 3 years later.

abutment was put over the implant. Impression was taken for final crown (Figure 6). One day after, crown was ready and delivered to the patient (Figure 7). checked An angulated to ensure crown abutment position checked on implant to ensure(Figure crown5), position after that on implant (Figure 5), after that After 3 years of Implant placement the patient returned, she showed a little cervical porcelain suturing done. crackwas but the patient didn’t want to replace the crown (Figure 8). Follow–up x-ray reveal bone in t placement 3 days later the patient after implant recalled placement for sutures patient and recalled angulated for sutures removal and angulated the peri- apical pathosis location (figurethe 9).removal he implant. abutment Impression was over was the taken implant. forforfinal Impression crown (Figure was taken 6).10). No forbone finalloss crown (Figure 6). 5 years laterput the patient returned annual check-up (Figure was visible (Figure 11). as ready Oneand daydelivered after, crown to the was patient ready(Figure and delivered 7). to the patient (Figure 7).

Figure 9. OPT 3 years later. placement After 3the years patient of Implant returned, placement she showed the patient a little returned, cervical porcelain she showed a little cervical porcelain 28 n’t want cracktobut replace the patient the crown(Figure didn’t want 8). to replace Follow–up the crown(Figure x-ray reveal bone 8). Follow–up in x-ray reveal bone in checked to ensure crown position on implant (Figure 5), after that

Tel-Aviv University Dr. Zeev Ormianer, Prosthodontist, DICOI Director, Implants Prosthodontic Clinic Credits andOral Special Appreciation Department of Oral Rehabilitation School of Dental Medicine Dr Zeev Ormianer, Prosthodontist, DICOI Director, Oral Implants Prosthodontic Clinic Tel-Aviv University

Department of Oral Rehabilitation School of Dental Medicine Tel-Aviv University Page 3

Page 4

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‫‏‬Immediate implant placement

5 years follow up of extraction & immediate implantation of tooth with peri-apical pathosis ‫‏‬Samier Askar, DDS,* and Tamer Abu Sada, DDS ±

References 1. Lemongella G: customized provisional abutment and provisional restoration for an immediately-placed implant PPAD 2007;19(7):419-426. 2. Rubinstein S, Salama M: the reverse pathway: parameters for the integration of function and aesthetic with implants JIACD 2010;2(4):19-29. 3. Mathews DP: Soft tissue management around implants in the esthetic zone. Int J Periodontics Restorative Dent 2000;20(2):141-149. 4. Hansson S, Werke M: The implant thread as a retention element in cortical bone: the effect of thread size and thread profile: a finite element study Biomech 2003;36(9):1247-1258. 5. Tarnow DP, Emtiaz S, Classi A: Immediate loading of threaded implants at stage 1 surgery in edentulous arches: ten consecutive case reports with 1 to 5-year data. Int J Oral Maxillofac Implants 1997;12(3):319-324. 6. Jundslalys G. Immediate implantation and soft tissue reaction. Clin Oral Implants Res 2003;14(2):144-149. 7. Touati B, Guez G. Immediate implantation with provisionalization: From literature to clinical implications. PPAD 2002;14(9):699-707. 8. Spear FM. Maintenance of the interdental papilla following anterior tooth removal. PPAD 1999;11(1):21-28. 9. Wöhrle PS. Single-tooth replacement in the aesthetic zone with immediate provisionalization: Fourteen consecutive case reports. PPAD 1998;10(9):1107-1114. 10. Saadoun AP, Le Gall MG, Touati B. Current trends in implantology: Part II–Treatment planning, aesthetic considerations, and tissue regeneration. PPAD 2004;16(10):707-714. 11. Gomez-Roman G. Influence of flap design on peri-implant interproximal crestal bone loss 30

around single tooth implant. Int J Oral Maxillofac Impl 2001;16(1):61-67. 12. Small PN, Tarnow DP, Cho SC. Gingival recession around wide-diameter versus standarddiameter implants: A 3- to 5-year longitudinal prospective study. Pract Proced Aesthet Dent 2001;13(2):143-146. 13. Cocchetto R, Vincenzi G. Delayed and immediate loading of implants in the aesthetic zone: A review of treatment options. Pract Proced Aesthet Dent 2003;15(9):691-698. 14. Hermann JS, Schoolfield JD, Nummikoski PV, et al. Crestal bone changes around titanium implants: A methodologic study comparing linear radiographic with histometric measurements. Int J Oral Maxollofac Impl 2001;16(4):475-485. 15. Morris HF, Ochi S. The influence of implant design, application, and site on clinical performance and crestal bone: A multicenter, multidisciplinary clinical study. Dental Implant Clinical Research Group (Planning Committee). Implant Dent 1992;1(1):49-55. 16. Buser D, Dula K, Belser U, et al. Localized augmentation using guided bone regeneration. Surgical procedure in the maxilla. Int J Periodontics Restorative Dent 1993;13:29–45. 17. Gher M, Quintero G, Assad D, et al. Bone grafting and guided bone regeneration for immediate dental implants in humans. J Periodontol 1994;65:881–891.

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‫ ‏‬omputerized C implant planning ‫ ‏‬unique, exclusive and patented service that enables you, the dentist, at the click of A a button on your computer, to plan a precise implantation procedure from your clinic. A Surgical Guide can be produced digitally from this 3D plan, to bring the virtual plan to the mouth. ‫ ‏‬B Guided Service will prepare a treatment plan according to your instructions, A and present to you 2D and 3D images in AB Denpax web-based technology. ‫‏‬You can view the plan, consult with colleagues or dental laboratory (as the location of the restorations can be seen in the virtual plan) and either request changes or approve the plan. ‫ ‏‬fter the treatment plan is approved, a surgical guide is manufactured digitally, A directly from the planning software. ‫‏‬AB Guided Service is designed for users of AB Implants. The process so easy, that you can use surgical guides for even 1 implant. ‫ ‏‬B Guided and AB DENPAX provide this service for you, with all the images you A need to view your plan. ‫‏‏‬The surgery takes less time, and both you and your patient are more relaxed. ‫‏‬This technology will allow you to use your knowledge of implantology in a more efficient and safer way. 33


Case

1

Computerized implant planning

7‫‏‬Implants Maxilla Dr. Korf Eitan

In this partially edentulous maxilla, 7 implants were placed. The upper right was flapless, and in the left side, a flap was opened. Implants were inserted in the anterior region, following extractions of the teeth.

Figure 1: Axial view of planned implant position

Figure 3: Panoramic slice

34

Figure 2: Volume panoramic view

Figure 4: Virtual guide in 3D plan

Figure 5: Digitally produced surgical guide with colored sleeves. The colors match the drill colors

Figure 6A+B: These views show the relationship of the planned implants to the teeth to be extracted, and to the Teeth remaining

Figure 6C: These views show the relationship of the planned implants to the teeth to be extracted, and to the Teeth remaining

Figure 7: Drilling with 30mm drill and 2.5mm diameter drill tool

Figure 8: Drilling with 21mm drill and 2.5 diameter drill tool

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Computerized implant planning

7 Implants Maxilla

Case

2

Computerized implant planning

4 Implants Maxilla with Full Flap Dr. Ziv Simon

Dr. Korf Eitan

‫‏‬A Full Flap was opened due to the lack of attached and keratinized gingival tissue

Figure 9: 2 implants with healing screws. A flap was opened

36

Figure 10A: Panoramic view of the CT in the plan

Figure 1: Upper Jaw showing missing teeth

Figure 2: Panoramic Views of Planning

Figure 10B: Panoramic view of the CT in the plan

‫‏‬Figure 4: The sagittal images for all implants

Figure 11: Post operative panoramic xray

Figure 5: 3D

Figure 6: 3D

Figure 3. Axial View of Plan in Coronal area

Figure 7: 3D Images in Planning

37


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Computerized implant planning

4 Implants Maxilla with Full Flap Dr. Ziv Simon

38

Figure 8: 3D Images in Planning

Figure 9: 3D Images in Planning

Figure 10: 3D Images in Planning

Figure 17: Depth Check

Figure 18: Depth Check

Figure 19: 2.8‫‏‬Drill Blue 25mm

Figure 11: 3D Images in Planning

Figure 12: AB Guide on 3D Printed Model

Figure 13: Guide in Position

Figure 20: Implant through Guide

Figure 21: Implants Inserted

Figure 22: Implants in Bone

Figure 14: Implant positions marked using guide. Planned flap design

Figure 15: Flap opened

Figure 16: Pilot 2mm Drill-Blue 25mm

Figure 23: Flap Closure with Sutures

Figure 24: Post-Op Periapicals

Figure 25: Post-Op Periapicals

39


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Computerized implant planning

4 Implants Maxilla with Full Flap

‍�‏Immediate loading

Dr. Ziv Simon Functional and aesthetic restoration that is achieved as early as possible is the aim of every operator. This principle has formed the ground for immediate loading of dental implants. The idea of immediate loading went into use in the very early stages of the dental implant world. The failure rate of these attempts was very high and often failure occurred soon after loading. Despite these failures, many of the attempts at immediate loading were very successful and lasted for many years. Figure 26: Post-Op Periapicals

Figure 27: Temporary Bridge

A number of factors contributed to the high failure rate, including the properties of the implants' metal. Despite it being proved that the metal is biocompatible, it did not have the strength required for supporting prosthodontic restorations. In addition there was a lack of necessary surgical and prosthodontic knowledge. As the metals for producing the implants improved, restoration by immediate loading returned. In addition, documentation shows high success rates for this treatment.

40

41


Case

1

‫‏‬Immediate loading

Sinus lift operation Dr. Benjamin Retzkin

Secondary caries was found in a 50 year old male patient in teeth 14, 15 under crowns. Tooth 16 is missing. Teeth 14, 15 were extacted and a sinus lift operation was performed, implants were installed and immediate loading was performed.

≥ Figure 27

42

Figure 1: Periapical x-ray of teeth 14&15; for extraction

Figure 2: Site after extractions

Figure 3: Open window in the sinus

Figure 4: Sinus augmentation procedure

Figure 5: Implantation with bone substitute

Figure 6: Use of membrane to cover implants

Figure 7: Periapical x-ray of implants

Figure 8: Soldering of the implants

Figure 9: Temporary bridge

43


Case

2

‫‏‬Immediate loading

Immediate loading Dr. Benjamin Retzkin

A 65 year old male patient suffers from caries in his lower incisors (figure 1, 2). The treatment plan involves extraction of 32, 33, 34, 41, 42, installation of 4 implants (figure 3), fixation of implants by soldering (Figure 4) and immediate loading using an acryl temporary bridge, which was copied from an alginate impression that was taken from the original bridge (Figure 5). After about 4 months of waiting, a permanent bridge was performed.

44

Figure 1

Figure 2

Figure 4

Figure 5

Figure 3

‫ ‏‬crew-retained S restoration on implant ‫ ‏‬crews are not only used to attach abutments to implants but also the restoration S component to the abutment. ‫‏‬Screw retention allows retrievability. Alterations, extensions, and repairs of the restoration can be done easily. Access to the implants in case of necessary soft tissue management is guaranteed. The dentist will be able to complete implant prostheses even in very difficult cases. In spite of the obvious advantages of screwed implant restorations, their esthetic disadvantages and screws’ structural disadvantages should be considered. ‫‏‬Screws designed for different purposes have different mechanical properties because of their size, design, and metallurgic composition. Screws should be tightened to 50% to 75% of their yield strength to provide optimum clamping force. ‫‏‬In a situation where there is an accurate fit between the head of the implant and the abutment, a continuum of pivot points is created around the circumference. In this stable situation, vertical occlusal forces that occur over the prosthetic head of the implant will produce vertical loading and will not stress the screw or cause screw loosening. 45


Case

1

Screw-retained restoration on implant

Case

CONSERVATIVE vs INVASIVE APPROACH TO IMPLANT SUPPORTED RESTORATION IN IMPACTED UPPER CANINE

2

‫‏‬Dr. Gil Rafalovitz

Screw-retained restoration on implant

Screw-Retained Implants ‫ ‏‬r. Nikolay Igorevich Vasil’yev D Dr. Alexei Petrovich Rashtanikov

A Female patient presents with a full upper bridge on the brink of collapse due to extensive secondary caries. The upper right canine is fully impacted. This, in combination with the size of the sinus cavity, does not allow a simple implantation in the anterior area.

In this article, clinical situations are examined involving prosthetic implants (for example, the A.B. Dental system of implants), in which the use of screw-type attachments for crowns remains the only option. The advantages and disadvantages of screw-retained implants will be examined in comparison with dental cements, as well as key moments in taking impressions from implant level.

The dilemma is whether to surgically remove the impacted tooth, thus destroying the palatal bone and having to put the patient through the procedure of bone augmentation OR to introduce the implants at an angle to take advantage of the existing bone.. Using tilted implants, it is possible to save the patient from a more complicated surgical procedure (removal of the canine and bone augmentation) and send the patient back home with a temporary screw retained restoration on the same day. This gives the patient immediate quality of life and comfort.

Figure 1

46

Figure 2

Figure 3

Figure 1

A rather common clinical situation is shown in the x-ray (Fig. 1): some molars and pre-molars are missing on the left and right. From the standpoint of implantology, the situation is not complicated; it is resolved with simple implants without additional bone augmentation. However, the patient’s first requirement was to preserve his remaining teeth and restore the lost ones; therefore, in planning his orthopaedic treatment, we need to take into account the presence of both third molars on the lower jaw, which must be preserved. To ensure that the future structures are properly implanted, in a number of cases it is worth considering extraction of the eighth teeth – this is due, first of all, to their undesirable angle. The angle will lead to the contact point being situated too high and the so-called “black triangle” will remain, because of the fact that the interdental papilla cannot fill an interdentium that is too large. This problem is solved on the right side by mounting an artificial crown of the required shape at 4.8, which will allow the lower point of contact to interlace as closely as possible to the gingiva. 47


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Screw-retained restoration on implant

Screw-Retained Implants ‫ ‏‬r. Nikolay Igorevich Vasil’yev D Dr. Alexei Petrovich Rashtanikov

Thus, the implants are mounted following a two-stage methodology; implant exposure may begin after three months (Fig. 6). Analysis of the intermediate situation prior to prosthesis identified the following. The level of the attached gingiva is sufficient; however, the volume of the soft tissues is extremely scanty and it is assumed that after the implant exposure, the desired height of the free marginal gingiva around the neck of the future crowns will not be reached (Fig. 7, 8, 9). In the photographs (Fig. 12), the thinning mucosa can be seen, through which the metal of the plugs is visible. Removal of the soft tissues in the vestibular-lingual direction during the implant exposure procedure will insignificantly raise the level of the gingival margin (Fig. 13, 14, 15, 16). The final picture after healing shows this (Fig. 17, 18, 19).

Figure 12

Figure 13

Figure 14

Figure 15

Figure 16

Figure 17

Figure 18

Figure 19

Figure 20

Figure 6

Figure 7

48

Figure 8

Figure 9

49


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Screw-retained restoration on implant

Screw-Retained Implants ‫ ‏‬r. Nikolay Igorevich Vasil’yev D Dr. Alexei Petrovich Rashtanikov

Figure 21

Figure 22

After completion of implant exposure or even prior to this, it is necessary to take a simple alginate impression from the lower jaw in order to make a custom tray (Fig. 20, 21). When making the tray, it is necessary to determine the method for taking the impression from implant level. The method depends on certain anatomical characteristics specific to the patient: the inability to open the mouth sufficiently wide is a serious hindrance. This makes it difficult to use impression copings with screw retainers. In addition, taking the impression by the “open tray” method is impossible, the more so because of the longer impression copings (Fig. 22). Hence we must conclude that the most suitable method turns out to be impression copings that do not have screw-type attachments. This means the so-called Clip-transfer copings, or transfer copings with clip fasteners (Fig. 23). In our case, this is the most convenient solution. To take the impression, we will use a “closed” tray.

Figure 23

Figure 27

The transfer copings with the clip attachments lock into place exactly and definitively in the implant’s hexagonal interlocking (Fig. 26). After this, they are secured among themselves into a unified whole using a fast-hardening cement (Fig. 27). Splinting of the impression transfers is mandatory, because it reliably ensures that the implants are properly positioned with respect to one another for the future model and is a guarantee of a passive fit for the future dental prosthesis. After taking the dual-phase, single-stage silicon impression (Fig. 28, 29, 30), we will accurately mount implant replicas to the clip fasteners on the transfer copings (Fig. 31). We ensure their reliable positioning in the thickness of the silicon: the slightest vibrations of the transfer copings in the impression are NOT ALLOWED (Fig. 32).

Figure 28A

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Figure 26

Figure 28B

Figure 28C

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Screw-retained restoration on implant

Screw-Retained Implants ‫ ‏‬r. Nikolay Igorevich Vasil’yev D Dr. Alexei Petrovich Rashtanikov

Figure 29

Figure 30

Figure 31

insignificant. An option could still be the use of zirconium abutments in combination with non-metallic crowns; however, our patient’s requirements amounted to a restoration that is as simple as possible. It is fortunate at least that the attached gingiva is entirely sufficient; additional mucogingival operations are therefore not planned. The crowns on the screw-retained implants have a ceramic coating that begins from the screwimplant joint itself; this prevents dark bands of metal from appearing with the passage of time due to shrinkage of the soft tissues. Proceeding from the above and paying attention to the fact that we plan to restore the teeth in the masticatory section, the screw-retained implants for the metal-ceramic crowns will be a proper and simple solution.

Figure 32

What kind of implant insertion should we select? Screw-retained or cement? To decide, we must proceed from the situation and from the aesthetic goals that we want to achieve. In our situation, there is at least one weighty circumstance compelling us to turn to screw-retained implants for the crowns: the marginal soft tissues around the implants are not high and they have very little volume (Fig. 17, 18, 19). In this case, it is complicated to conceal the cement bond for the metal-ceramic crown and the standard titanium abutment under the gingiva. Even if we manage this, it is difficult for us to guarantee that its aesthetic nature will not deteriorate over the course of time. When the height and volume of the soft free tissues are small and a crown is still mounted with cement, the shape of the prepared abutment is extremely thin, and the size of the chamfer is 52

Figure 48

Figure 49A

Figure 49C

Figure 49D

Figure 49B

53


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Screw-retained restoration on implant

Screw-Retained Implants ‫ ‏‬r. Nikolay Igorevich Vasil’yev D Dr. Alexei Petrovich Rashtanikov

This series of photographs (Fig. 49) shows the laboratory phases in developing a crown with a screw-retained implant: the crude shape of the unprocessed metal frame; the frame, coated with a layer of Opaquer placed in the screw shaft; as well as a demonstration using an implant replica (Fig. 50) to show that the precision of the joint for this crown is sufficient. The clinical photographs of the screw shaft being closed first with Teflon tape, then with resin luting (Fig. 51, 52) convincingly demonstrate satisfactory aesthetics. The way the metal surface is completely enclosed should be considered a nice touch here.

Figure 54

Figure 55

Figure 56

Figure 57

Figure 58

Figure 59

Figure 60

Figure 61

Figure 62

On top of this, the use of the screw-type attachment for the crowns with this patient has allowed the restoration to be tightly and controllably adapted to the surface of the marginal gingiva. The short-term ischemia of the soft tissues in the photographs (Fig. 53, 54, 55) epitomizes this. The final view (Fig. 56 – 59) meets our expectations. The mandatory x-ray image of the mounted crowns confirms the accuracy of the joints (Fig. 60, 61, 62).

Figure 51

54

Figure 52

Figure 53

55


Case

3

Screw-retained restoration on implant

Screw-Retained restoration ‫‏‬Dr. Nikolay Igorevich Vasil’yev Dr. Alexei Petrovich Rashtanikov

The distinguishing feature of this clinical case is that a metal-ceramic implant-supported bridge will be mounted. This is an acceptable option in situations where the patient has limited financial resources, in which three missing teeth are restored with two implants. The x-ray (Fig. 63) shows the initial situation, from which we can see that practically every wellanchored tooth needs medical attention (Fig. 64). We began rehabilitation by extracting the badly damaged and demineralized root of tooth 3.5 and all third molars (Fig. 65).

Figure 63

Figure 64

56

Figure 66

Figure 65

Figure 67

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Screw-retained restoration on implant

Screw-Retained restoration ‫‏‬Dr. Nikolay Igorevich Vasil’yev Dr. Alexei Petrovich Rashtanikov

Two and a half months after tooth 3.5 was extracted, the condition of the bone has become suitable for dental implants (Fig. 66). During this time, the remaining teeth have been undergoing treatment and restoration. Implants were mounted in the location of missing teeth 4.6, 3.5, and 3.7 (Fig. 67). Immediately after the operation for the 4.6 implant, a healing abutment (Fig. 71, 73) was installed; 3.5 and 3.7 undergo a two-stage methodology. The inadequate volume of the soft tissues in the third dentition segment was satisfactorily replenished after implant exposure (Fig. 69, 70). Attached portions of the gingiva were created; however, the height of its free margin around the implants is not large (Fig. 72). As was noted in the description of the first clinical case, this can be considered as a point in favour of screw-type attachments for the crowns.

Figure 72

Figure 73

Figure 74

Moreover, screw-type attachments are given priority during bridge construction because of the need to achieve a solid abutment of the intermediate parts (artificial tooth 3.6) to the mucosa ridging. It is very complicated to do this in a predictable and controlled manner using cement retention, because the pliability of the soft tissues sometimes is complicated to negotiate by force of fingers. Figure 75

Taking an impression from the implant level pursued the most basic goal – to transfer the spatial positioning of the implant, with a high degree of precision, to the working model in the laboratory.

Figure 69

58

Figure 70

Figure 71

The primary guarantee of this is the strict position of the impression copings on the thickness of the mould – without the slightest disturbance. To do this, an open tray impression coping was used for the 4.6 implant, and two impression copings with clips on the third segment. The impression coping is kept immovable by only one thing: its irregular shape. Therefore individualizing the shape using a fast-hardening cement proves successful (Fig. 74). 59


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Screw-retained restoration on implant

Screw-Retained restoration ‫‏‬Dr. Nikolay Igorevich Vasil’yev Dr. Alexei Petrovich Rashtanikov

The longevity of the “crown-implant-bone” system was guaranteed by the passive role in mounting a superstructure, which means that a precise mutual positioning for the copings in the impression will be key. Specifically based on this, splinting the copings must be strictly mandatory (Fig. 75). This can be done in different ways. In our case, the handle from a microbrush with flattened ends was used, which was secured with cement. In this section, the coping tray will be a “closed” type.

For the 4.6 implant, owing to the sufficient volume of soft tissues, we manage without difficulty to conceal the cement joint under the gingiva. For this, the width of a standard titanium abutment was completely sufficient (Fig. 81, 82).

After taking the impression, the replica implants are placed onto the copings by traditional method (Fig. 76 - 80), after which we will ensure that the position of the copings is rigid and secure.

The prosthetic bridge that was prepared has the same specific features for fabricating the screw shaft as in the first clinical case; the intermediate part of the prosthetic was made in an ovoid shape, which will give the marginal gingiva a more natural shape after compression and, we predict, will spare the patient from tiresome impaction of food in this section.

Figure 76

Figure 81

Figure 77

Figure 78

Figure 82

Figure 88

Owing to the regularly formed shape of the soft tissues and to the moderate pressure of the titanium abutment, crown implant 4.6 did not pose any difficulty, and the abutment has a natural and attractive appearance (Fig. 87 - 89).

Figure 79

60

Figure 80

Prosthetic bridge implants are performed only under anaesthesia. In the event that the soft tissues are excessively pliable in the projection of the intermediate section, it is recommended that the volume of slightly injured gingiva be reduced with a coarse-grained diamond burr. Ischemia of the gingiva after the implants for a brief time is expected and inescapable (Fig. 90 - 91). 61


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Screw-retained restoration on implant

Screw-Retained restoration ‫‏‬Dr. Nikolay Igorevich Vasil’yev Dr. Alexei Petrovich Rashtanikov More importantly, what we wish to draw the attention of the operators to when making an x-ray of the crowns and abutments, is the vertical component of the implant. The x-rays show examples where the crowns with screw-retained implants are not completely fitted (Fig. 97, 98).

Figure 89

Figure 90

Figure 91

Figure 93

Figure 94

Figure 95

Figure 96

Figure 97

Figure 98

Figure 92

During quality control we note the following peculiarity. The screw-type joint for hexagonal and round abutments appear differently in the x-rays. Specifically, a crack was noted between the inner joint of the implant and the non-engaging abutment (Fig. 92, 94). In connection with this was the sensation that the crowns (abutments) were not attached all the way to the end. However, the presence of the crack is simple to explain: at a certain angle of the x-ray, the hexagon looks wider than the round joint Fig. 95). The position of the healing abutment on the implant can also serve as a convincing example of this (Fig. 96). 62

63


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narrow implants

Screw-retained restoration on implant

Screw-Retained restoration ‫‏‬Dr. Nikolay Igorevich Vasil’yev Dr. Alexei Petrovich Rashtanikov

Owing to the method described for preparing the screw shaft for closure, the resin plugs for the screw joints were not visible, and the final result looked brilliant, not only aesthetically, but also functionally (Fig. 90 - 102).

Figure 99

Figure 100

Implants of narrow diameter (less than 3.75) have existed since 1990 and are an example of the use of a certain implant size has very clear indications. In effect, the choice of implant diameter depends on the type of tooth deficiency, the remaining bone volume, the gap to be restored prosthetically, the eruption profile and the occlusion type. Narrow implants are suitable for very specific clinical conditions. For example, when there is a missing tooth between two roots or when there is a narrow alveolar ridge and a need to replace a narrow necked tooth. In general, the guidelines that have been developed for installing ordinary implants followed by prosthodontic restoration may be applied to the installation of narrow implants too.

Figure 101

Figure 102

64

65


Case

1

Narrow implants

A clinical case demonstrating the use of narrow implants ‫‏‬Dr. Benjamin Retzkin

While planning a dental implantation one must take into account the physical constraints of the individual case. For example, in cases in which the horizontal space is limited between teeth or roots sitting close to one another, or when there is a narrow alveolar ridge. Using narrow implants avoids the need for ridge augmentation or orthodontic movement of the teeth. Also, in cases in which a tooth is missing and the space between teeth is narrow, narrow implants may be the sole option.

The last option was chosen, which gave a stable restoration and rotation was prevented. The space between the new implants and the existing ones ranged from 2.5 to 3 mm. I5 implants were chosen with a 3 mm diameter and 10 mm length from A.B. Dental Devices Ltd. (figure 4). The papilla from the adjacent implants was maintained (figure 5). A clinical and radiological examination show correct placement of the implants (figure 6-7).

A woman of 75, systemically stable, is requesting rehabilitation of teeth 11 and 12 (figure 1). The space between teeth 13 and 21 is 13 mm (figure 2) and the ridge thickness is 5.5 mm (figure 3). The patient has restored implants, which resulted in a satisfying aesthetic result to the patient’s satisfaction and lasting already for many years.

Figure 1: CT

Figure 2: The space between teeth 13 and 21 – 13 mm

Figure 5: The papilla from the adjacent implants was maintained

Figure 6: Clinical image of the implants

Figure 7: X-ray image of the implants

Figure 3: Ridge thickness is 5.5 mm

Possibilities for rehabilitation, as discussed with Dr. Naomi Reshef (rehabilitating dentist), included: + Partial removal of the existing restoration and placement of a partial fixed prosthesis to bridge the gap between 11 and 12. + Augmentation of the ridge and placing one implant at the place of teeth 11 or 12 and the placement of a partial fixed prosthesis on the implant with a Pontic. + 2 narrow implants of 3 mm diameter. 66

Figure 4: I5 implants with a 3 mm diameter and 10 mm length, from AB Dental Devices Ltd.

67


Case

2

Narrow implants

Case

Two narrow implants instead wide one ‫‏‬Dr. Gustavo Yatzkaier

68

3

Narrow implants

Narrow implants ‫‏‬Dr. Gustavo Yatzkaier

Area of 36, a gap between 35-37 of more than 15 mm, in this case two narrow implants or one wide implant could be chosen; as according to the CT image, the width was borderline, it was decided to install two 5 3/13 implants, healing caps were laid on the day of the operation.

Left maxilla, area of 22-23-24, narrow ridge. A number of treatment options: + Bone implantation as a preliminary procedure and after 5 months execution of 3 wide implants. + Executing implants and implantation of bone grafting simultaneously. + Execution of 3 narrow implants. After a talk with the patient and the prosthodontist, 3 narrow implants were executed - 5 3/13.

Figure 1: panoramic section of CT image

Figure 2: cross section for a CT shows a borderline width

Figure 1: panoramic section from preoperative CT image

Figure 2: cross-sectional images from CT scan showing borderline width

Figure 3: periapical x-ray image after the implantation

Figure 3: 2 implants in place, including healing caps before suturing

Figure 4: after suturing

Figure 4: clinical appearance before uncovering

Figure 5: full coverage of implants 22-24 and partial coverage of 23

Figure 6: laying of healing caps

Figure 5: PA image after the procedure

69


Case

4

‫ ‏‬inus lift S operation

Narrow implants

Narrow implants ‫‏‬Dr. Benjamin Retzkin

A 60 year old male patient, with all 4 lower incisors missing (Figure 1), asks for a permanent solution. Upon clinical examination (Figure 2) and CT image (Figure 3) of the alveolar ridge, it was found that he had adequate bone volume for installing implants. The implants that were chosen are narrow implants of 3 mm diameter, for achieving a better aesthetic and clinical result. The implants were installed without lifting a flap (Figures 4,5,6). After 3 months, the prosthodontic restoration was performed (Figure 7).

The method allows for increasing the ridge height, thus allowing for the installation of implants of common lengths. In addition to the various techniques that were developed for lifting the sinus floor, there are many variables that may affect the outcome of this procedure.

Figure 1

70

Insufficient height of the alveolar bone is a common restriction in installing dental implants in the distal maxilla area. Executing a bone implant in the floor of the maxillary sinus has become a common surgical method for repairing bone deficiencies in this area. This method was first published by Boyne and James in 1980 and was subsequently modified by various clinicians.

Figure 2

Figure 3

Figure 4

Figure 5

Figure 6

Figure 7

These include immediate implant installation with lifting of the floor of the sinus or later implantation, use of a membrane as a barrier on the lateral window, use of various bone substitute types and the use of dental implants with different surfaces and length and width characteristics. Moreover, the effects of smoking and residual bone height may also affect the outcomes.

71


Case

1

Sinus lift operation

Sinus lift operation Dr. Benjamin Retzkin

A female patient aged 70 had implants installed about 10 years ago. An implant in the place of tooth 15 fractured due to overload.

The bone height in the area is insufficient and a sinus lift is necessary. Sinus lift operation was performed using a xenograft andallograft (Figures 5, 6); at the same time the fractured implant was removed (Figure 7) and two implants installed (Figure 8).

Figure 2

Figure 3

Figure 4

Figure 6

Figure 7

Figure 8

Figure 5

72

73


Case

2

Sinus lift operation

Case

Open sinus lift and two-stage implantation Dr. Gustavo Yatzkaier

If the width and thickness are not suitable for performing sinus lift surgery and implantation simultaneously, it can be done in two stages. Stage A - open sinus lift without implants Figure 1, panoramic section of CT image that shows lack of bone height. Figure 2, cross sections of CT that show a lack of width. Figure 3, panoramic x-ray image after sinus lift operation that shows bone substitute inside the sinus. Stage B - after 7 months, the implants may be performed. Figure 4 implants in place. Figure 5 periapical x-ray image that shows implants in place. Figure 6 implants have been uncovered. 74

3

Sinus lift operation

Open sinus lift and implantation Dr. Gustavo Yatzkaier

When it is necessary to perform an open sinus lift operation for installing implants, there are a number of questions for us: + Is it possible to perform a sinus lift operation and install implants in the same surgical procedure? + What temporary prosthetic restoration may be given to the patient? + How long will it take? Figure 1

Figure 3

Figure 2

Figure 4

Insertion of implants during an open flap lift operation is possible when the patient has more than 2 mm of bone height, at least 4 mm of bone width, the bone quality provides the implants initial stability and the course of the operation is normal, without mucosal tearing or minimal tearing. In this case, because the residual bone width and height were sufficient, it was decided to perform the sinus lift and implanting simultaneously. As a temporary prosthetic restoration, it was decided to install a bridge on teeth 13-17, knowing in advance that they are lost teeth that were kept only for the temporary prosthetic restoration. The patient was given an explanation that the procedure would be performed in stages. Stage A - open sinus lift operation without implants (panoramic section from a CT scan showing enough bone length).

Figure 5

Figure 6

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Sinus lift operation

Open sinus lift and implantation Dr. Gustavo Yatzkaier

Stage B - after 9 months, the implants were uncovered (figure 8) and the patient was sent to the prosthodontist for having a new temporary bridge on the implants, including a cantilever bridge on 13, and when it was ready, stage C was performed. Stage C - extraction of 13-17 and immediate implant 13.

Figure 1,2: (cross sectional image from a CT scan)

Figure 4: lifting of sinus mucosa

Figure 5: insertion of 3 implants after filling in the sinus using bone substitute

Figure 7: PA x-ray image that shows 3 implants and bone substitute in the sinus after the procedure

76

Figure 3: lifting of a flap and fenestration, the mucosa of the sinus before lifting is visible

Figure 8

Figure 9: immediately after extraction of 13

Figure 10: insertion of immediate implant

Figure 11: implant in place

Figure 12: insertion of healing cap and filling of alveolar sockets with bone substitute

Figure 13: PA x-ray image with 13 in place

Figure 6: laying of membrane on the lateral wall of the sinus and covering screws on the implants

77


TEMPORARY IMPLANTS ‍ �‏or installing dental implants that will provide an aethetic and functional answer, F it is sometimes necessary to build or compensate for states of alveolar bone deficiency. For creating a ridge of sufficient height and width, augmentation operations must be performed. After performing the augmentation, about six months of recovery time are required. During the recovery time, it is best to avoid loading the bone graft, to prevent its resorption. A denture that leans on the bone graft may cause resorption. Temporary transitional implants that allow for immediate loading have recently been developed to allow for restoration using a fixed temporary denture that gives the patient improved aesthetics and functioning during the bone graft uptake period. The temporary implants are located lingually to the grafted bone and provide retention for a temporary prosthetic restoration that is not removable. This way,the recovery process may take place without a load being exerted on the bone graft or soft tissue.

78

79


Case

1

Temporary implants

TEMPORARY IMPLANTS ‫‏‬Dr. Benjamin Retzkin

A 40 year old female patient; upon clinical examination her mandible was found to have missing teeth (figures 4, 5). In the current condition, implants cannot be installed (Figures 7). The treatment plan involves thickening of the alveolar ridge using allogenic bone blocks (Figures 8, 9, 10) and loading on temporary implants until healing (Figures 11, 12, 13). Later, 6 implants with a wide prosthodontic platform will be installed.

80

Figure 7: Narrow alveolar ridge disable implantation

Figure 8: Bone

Figure 9: Thickening of the alveolar ridge

Figure 11: Performing temporary implants

Figure 12: Fixation of the implants

Figure 1: CT

Figure 2: CT back area

Figure 3: Front area with removable denture

Figure 10: Thickening of the alveolar ridge for implantations

Figure 4: Partial lack of teeth in the lower jaw

Figure 5: Partial lack of teeth in the lower jaw

Figure 6: Performing extractions

Figure 13: Fixation of the implants by soldering

81


Case

2

Temporary implants

TEMPORARY IMPLANTS ‫‏‬Dr. Benjamin Retzkin

A 60 year old female patient presented with a complaint of mobile lower teeth. An x-ray revealed that implants in the 33-43 area had failed. After removing the implants, curettage was performed and 6 temporary implants were installed along with a bone graft. A temporary denture was delivered, which was mounted on the temporary implants using the implant guide (see panoramic X-ray image). After a few months, 6 permanent implants were installed in a buccal position for supporting the lip.

Figure 1: First Panorex

Figure 3: bridge after its removal

82

Figure 2: clinical x-ray before treatment

Figure 4: site after extractions

Figure 6: narrow ridge for implantation

Figure 7: temporary implants

Figure 8: temporary implants

Figure 9: bone augmentation

Figure 10: use of membrane to cover implants

Figure 11: sewing

Figure 5: flap procedure

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Temporary implants

TEMPORARY IMPLANTS ‍�‏Dr. Benjamin Retzkin

Figure 12: use of implant's carrier to stabilize temporary denture

Figure 13: sewing; use of the carrier

Figure 15: panorex w/temporary denture

Figure 17: removal of temporary implants and inserting the permanent ones

84

Figure 14: temporary denture

Figure 16: removal of temporary implants and inserting the permanent ones

Figure 18: removal of temporary implants and inserting the permanent ones

Figure 19: implantation after several months

85


AB Dental Devices Ltd. Tel. +972.8.8531388 Fax. +972.8.8522562 www.ab-dent.com

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