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The zone comprised of the bone and soft tissues from the top of the implant through the soft tissues is not well understood by both dental technicians and dentists. Frequently, little or no consideration is given by the dentist as to the design of the abutment or implant restoration as it relates to this peri-implant tissue zone. For many dentists, the healing abutment is simply removed and a perfunctory mechanical impression is made by merely connecting a cylindrical fixture level impression coping to the implant and picking it up with impression material without regard to the anatomical contour (Fig. 1). The technician then pours up a cast with a fixture analogue often with no information or instructions conveyed by the dentist as to the abutment design parameters for the contiguous soft tissues. This results in the technician guessing as to the abutment emergence angle from the top of the implant, diameter and contour through the soft tissues. Impingement of the abutment on the bone or periosteum can have disastrous complications such as periimplantitis, loss of bone and gingival recession, or even implant failure. Improper abutment contour through thes soft tissues can also induce recession and peri-implantitis. A principal directive is to control all variables to avoid gingival recession around implant restorations.
As with all fixed prosthodontics the goal of the dentist-technician-surgeon team is to maximize clinical predictability in all aspects of implant dentistry in order to reduce the number of additional augmentive surgeries, avoid improper implant position which necessitates additional and more costly laboratory procedures, and avoid laboratory remakes due to improper restoration periimplant tissue contours. At every step of the implant prosthodontic process the team must endeavor to maximize the volume of peri-implant tissues. For an optimal clinical outcome the team can maximize predictability by paying meticulous attention to the key factors of:
• Treatment planning and site assessment
• Guidance for the implant surgeon to achieve correct implant placement
• Soft tissue site development with the provisional restoration
• Communication between dentist and technician in three dimensions
• Design and materials selection for abutment and crown
38 year old male, excellent general health with good supporting bone structure. The patient is a chronic mouth breather which accounts for some of the red areas in the anterior part of the mouth. His chief complaint was that the bridge “feels loose”.
After his initial visit with Dr. Cohen, a periodontist, the bridge was sectioned between teeth 9 and 10, tooth 8 was removed as was the retained root 9. Two Ankylos B 14 implants were placed with sulcus formers because of the deep placement of the implants and to facilitate the uncovering procedure. Three months later, the implants were uncovered by the periodontist and the sulcus formers were replaced with taller ones.
The patient was then referred to Dr. Goldenberg, a prosthodontist, to continue with the restorations. This was the patient’s first visit with the prosthodontist. Two weeks later the prosthodontist made a fixture level impression with two repositioning posts. The laboratory fabricated the soft tissue master cast with analogs of the Ankylos implants. Together with clinical images and the master cast, the prosthodontist and the author, a master dental technician, were able to tentatively fabricate a restorative treatment plan for the patient. Two problems were immediately apparent: the first was the discrepancy between the gingival level of the soft tissue on tooth 10 compared to tooth 7: the second was the extreme distance between the implant platform and opposing arch. In the laboratory, the abutment try-in kit was used to choose the appropriate abutment. These trial abutments are used to help estimate the angulation and soft tissue height for the Balance Abutment system. Our selection was a small 3.0/15° Balance Anterior abutment for both Ankylos implants. The problem we encountered was the lack of height of the abutment for proper retention of the future implant crown. Because of the compromised situation, the abutment had to be extended with a separate wax-up to “lengthen” the abutment which can be seen on the cast for this case.
Primary telescopes made of zirconium dioxide with electroplated secondary copings are the state-of-the-art of the telescopic crown technique (according to some publications). The esthetic advantage of the crown margin and the superb fit of the galvano copings are worth mentioning. But let’s remember the classic option! We are still able to manufacture precise telescopes made of premium gold alloy. The key advantage is the durability of the rugged margins.
Master Dental Technician Claus Küchler explains in this article that precious metal telescopes still fulfill all requirements of modern prosthetics.
Many dental technicians enjoy their work because of the challenges it brings, and that is the reason why we wrote this article. The initial situation was as follows: teeth 34 and 43 were prepared and 6 implants had been placed into regions 33, 35, 45 and 46. When we look at the model we can see the condition of the closed implants with the help of the defined healing caps. (Fig. 1).
All six posts should receive telescopes to support the tertiary structure. One look at the model and you can imagine the challenges the technician has to deal with to complete this work.
All technical reconstructions especially on implants have to be very precise. The dental technician has to have a medical understanding when it comes to implant restorations. He has to rethink the process!
Over the past years, rehabilitation of complete or partial tooth loss due to the different reasons with implant-supported or retained suprastructures has become a well-accepted treatment modality. The main aim for clinicians is to create restorations that are completely integrated in the dentofacial complex, histologically, functionally and esthetically1.
The replacement of a single anterior tooth can be one of the greatest surgical, restorative and esthetic challenges in dentistry. Dental implants continue to define the standard of care for tooth replacement and transition can be found in the patients expectations for treatment outcomes. Restoring only the function is not more the only goal since patients now also expect optimal esthetic results 2. For highly esthetic locations in the dental arch, especially for patients with a high lip line, implant-supported single-tooth restorations are subject to the most exacting requirements, including optimal implant and superstructure positioning 3. The abutment serves as the connector from the implant placed into dental alveolar bone through the gingival mucosa to the crown restoration, directly affecting the esthetic appearance of the tooth and gingival structures 4.
Dental implants and abutments are usually fabricated from commercially pure titanium. However, the presence of a gray gingival discoloration may be attributed to a thin gingival tissue thickness in the area around the abutment that is incapable of blocking reflective light from the metal abutment surface3.
Therefore, the introduction of zirconium and aluminium oxide abutments among innovation in ceramic crowns, has been a major advantage for the esthetic implant dentistry 4. By utilizing these modern implant systems one can successfully meet these challenges. Furthermore, to achieve the patients’ functional and esthetic demands in the transitient period of the final restoration, the provisional restoration should be done and should meet the same criteria as the final restoration.
With fixed implant restorations, the reconstruction of lost gingiva poses a true challenge, especially when pink aesthetics need to be harmonized with anterior ceramic restorations. It is also a challenge because the fixed restoration, in contrast to removable dentures, does not allow a large amount of gingiva to be added while covering the mucosa for hygienic reasons. In the following, the author illustrates how the pink and white portions of implant-retained maxillary restorations can be harmonized.
Keywords: loss of tissue, implant restoration, ceramic layering, silicone key, superstructure, gingiva reconstruction.
It is unfortunately often the case that crowns must be excessively lengthened and over-contoured when a prosthetic gingiva reconstruction is required. This frequently occurs from not wanting to confront the loss of pink substance, and it is subsequently hidden, as if the area to be replaced ends at the cervix of the tooth. An aesthetic lack of proportion arises, immediately discerned by the eye as unnatural since the familiar proportions of tooth to gingiva were not retained.
A successful reconstruction in these areas makes all the difference between a natural effect and alienating disharmony.
For this reason, the pink and white areas must be built up in correspondence with natural proportions independent of whether the extent of pink aesthetics exceed the normal limits of conventional practice.
Christina Ketzinger and Andreas Hoffmann show a simple, yet very effective transfer and cementing key made of light cured acrylic. It is easy to produce and provides great safety for both dentist and patient.
New technologies often require new or at least altered procedures and processes to get them working. Only with these modified procedures the advantages of new prosthetic solutions can be established successfully in the daily practice. What that means in detail, shall be explained on the following case, which was solved with individually milled Procera Titanium abutments and a zirconium bridge veneered with Nobel Rondo porcelain.
It is quite an achievement in implant prosthetics today, that technicians have the freedom to create individual implant abutments in order to provide an optimal base for whatever kind of implant superstructure. Compared to standard factory implant abutments, this can be considered a milestone.
So in the actual case described, two abutments had been waxed up, scanned and sent to Procera (Nobel Biocare) by data transfer over the Internet. Some days later the custom machine milled Titanium abutments were available. Even though these abutments are rotation protected, it still has to be made sure that they are screwed on the implant in the correct of the three possible positions. It is sure helpful to code the abutments (Fig.1=8647c), especially when a larger number of abutments is needed for the case. However, when such a coding is used, both technician and dentist should agree that the markings are always facing towards labial/buccal.
We are requested to treat an elderly patient (96 years old), who has been wearing a removable complete maxillary and mandibular denture. The patient has been seeing the same practitioner for approximately thirty years. Her condition progressively changed to a fixed mandibular denture, to a combined denture stabilized by supra-radicular attachments and finally to a complete removable denture.
The patient is very lively, dynamic, independent and does not look her age. She wishes to stabilize her mandibular denture, which she considers unstable when compared to her old ones, that she found very comfortable.
The implant solution is proposed to her. She enthusiastically accepts, but states that she must be able to “ enjoy” this progress as quickly as possible, due to her age.
Almost immediate loading, without having to wait for complete osseointegration is proposed. This solution is accepted by the patient.
Once the implants were loaded, the denture was stabilized during the healing of the marginal periodontium phase, that is to say approximately three weeks after the implants were loaded. The stabilization of the denture – attachments is done intraorally.
Abstract: The intent of this report is to evaluate the influence of the locking pin retention mechanism on the behaviour of a mandibular implant retained overdenture. Data was combined from multiple studies and correlated to evaluate the different results obtained in denture retention whether it be non implant or implant related. While traditional dentures may meet the requirements of many patients, others require more stability and function, especially in the mandible where extreme ridge resorption has occurred and implant placement is necessary.
Nearly one third of North Americans older than 65 years of age are fully edentulous and necessitate artificial teeth replacement. Although many patients’ requirements can be met by the traditional denture, others need additional retention.
This is usually the norm for mandibular supported dentures that call for supplementary retention to increase stability, function and to improve aesthetics.
In the second part of this series, the special method for passivating the superstructures is described. Using SAE spark erosion, interfering contacts in the inner contour are safely and precisely removed. It is the imprecise fit of the superstructure that transfers stress to the inserted implants and then creates problems in osseointegration, even leading to the loss of the implants.
Keywords: Individualized titanium abutments, ceramic veneer, passivation of superstructures with spark erosion, cemented bridges in the maxilla of CoCrMo The 5/06 edition documented a case history and the interdisciplinary collaboration between the practice and laboratory up to the creation of the framework.
Since the superstructure is affixed to the implants with cement, it should have a tension-free seat. This is achieved by providing a tension-free fit by electrically removing interfering contacts and imprecise fits by means of spark erosion.
Peri-implant mucosal height essentially follows the crest of the alveolar bone; however, the determining factors in inter-implant papilla development are complex and may not be fully controlled by implant design features or surgical interventions (4,5 and 6).
Although bone height and thickness are major determinants of soft tissue height, factors such as tooth morphology, location of the inter-dental contact point, and arrangement and quality of soft tissue fibers can also influence soft tissue appearance. Lack of dento-gingivo-alveolar circular, semicircular, transeptal, interpapillary and intergingival fibers around implants constitutes a major obstacle in soft tissue appearance and management around implants (4, 6). Absence of inter-implant papillae causing an inter-implant “blacktriangle” continues to be a significant problem in dental implant aesthetics. Success of the final restoration depends not only on successful osseointegration and on the implant's functional load-bearing capacity, but also on the harmonious integration of the crown into the existing dental arch(1). The present article emphasizes the significance of engineered simulated tissue in modern implant dentistry, when surgically optimal tissue height cannot be achieved.
For many years the material of choice for dental implants and abutments was titanium. Despite of its good biocompatibility and mechanical properties, there is still a risk of the metal components being visible when such abutments are used. Therefore, for achieving optimal esthetic requirements, ceramic abutments were developed (2).
Projects qualify as outstanding or great only when their visionary planning and fabrication quality are checked against each other. Reaching one’s goal with a shared design requires a close evaluation of all basic conditions.
Hardi Mink CDT lets us look over his shoulder in this article, and using the example of an implant-supported total prosthesis demonstrates how you can achieve your goal with the right strategy, the right team, and optimal planning.
• Economic factors: predictability, reproducibility of results
• New materials for better esthetic results
• Functionality and ease of revision
For the successful completion of a project, all participants in its execution must be provided with the implementation plan and must contribute their special knowledge and know-how at the appropriate points.
This applies to nearly all areas of life, whether it’s architecture, design, sports, or the media.
If you want to keep pace with the top of Formula 1 racing, you will certainly need not only financial support but also great teamwork. Success actually comes from meshing builders, engineers, driver, and pit crew together – it makes little difference whether one individual is up with the latest technological developments, another has wide experience, another has driving skills, or whatever.
A great deal of precision and interdisciplinary collaboration is required in planning and fabricating implant-born restorations for edentulous or partially-edentulous patients. Many details have to be taken into consideration to ensure the long-term osseointegration of the implants. The subsequent case study by Prof. Dr. Gómez-Román and MDT Günter Rübeling describes a special procedure for precisely processing the mesostructures and superstructures along with the collaboration between the dental office and laboratory. By means of SAE spark erosion, metal structures can be passivated, i.e., without tension and interference, which are not passively seated on the osseointegrated implants.
Keywords: Impressions, first model, interdisciplinary collaboration, passive seat of the implants, position check, tension-free osseointegration Introduction: Description of the problem Mesostructures and superstructures that are not passively seated on osseointegration implants can cause mechanical and biological complications such as loosened screws, broken screws and implants, pain from tension, marginal bone loss and the loss of one or more implants.
The passive seat of mesostructures and superstructures on osseointegrated implants has been discussed in numerous scientific studies and is held to be an important prerequisite for the long-term osseointegration of implants.
The metal frameworks – identified as superstructures in the remainder of the article – that are fixed with screws to the implants or abutments or cemented to abutments, should have a tension-free seat. This requires a high degree of precision when manufacturing the superstructure, as well as constructive interdisciplinary collaboration between dentists and dental technicians.