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Title: DR SALAH HEGAZY Introduction To Dental Implant Definition


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Dental Implant
  • DR SALAH HEGAZY

3
Introduction To Dental Implant
  • Definition
  • Materials used for dental implant.
  • Types of dental implant
  • Osseointegration
  • Biomechanics of osseointegrated implant.

4
Definitions
  • Oral Implant
  • A device or inert substance, biologic or
    alloplastic, that is surgically inserted into
    soft or hard tissues, to be used for functional
    or cosmetic purposes.
  • Dental Implant
  • A permucosal device which is
    biocompatible and biofunctional and is placed
    within mucosa or, on or within the bone
    associated with the oral cavity to provide
    support for fixed or removable prosthetics.

5
Or Dental implant
  • prosthetic device of alloplastic material
    implanted in oral tissues beneath the mucosal
    or/and periosteal layer, and /or within the bone
    to provide retention support for a fixed or
    removable prosthesis
  • Made of various biomaterial. Most commonly made
    of titanium (most compatible with human biology)

6
introduction
  • Losing tooth/teeth is not new problem
  • It is possible to replace teeth that look
    function like natural teeth
  • Implants is one of the means of achieving this
    through osseointegration (biological adhesion of
    bone tissue titanium)
  • Pioneered by prof. Per-Ingvar Branemark in 1952
    ( Swedish orthopedics' surgeon)

7
Dental implants
8
Advantages disadvantages of implant over
conventional treatment
  • Implants do not involve preparation of the
    adjacent teeth, they preserve the residual bone,
    and excellent aesthetics can be achieved.
  • However, it is expensive, the patient requires
    surgery, time consuming, and technically complex.

9
Types of dental implant
  • Mucosal Insert
  • Endodontic Implant (Stabilizer)
  • Sub-periosteal implant
  • Endosteal or Endosseous implant
  • Plate-form implant
  • Ramus-frame implant
  • Root-form implant
  • Transosseous implant

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1. Titanium Mucosal Insert
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2. Endodontic Implant (Stabilizer)
  • Endodontic implants are similar to
    prosthodontic implants in many respects. However,
    they serve another purposethe stabilization and
    preservation of remaining natural teeth, not the
    replacement of lost teeth.

16
3. Sub-periosteal implant
  • Subperiosteal Implants were already
    introduced in the 1940s. Of all currently used
    devices, it is the type of implant that has had
    the longest period of clinical application. These
    implants are not anchored inside the bone, such
    as Endosseous Implants, but are instead shaped to
    ride on the residual bony ridge of either the
    upper or lower jaw. They are usually not
    considered to be osseointegrated implants.
  • Subperiosteal Implants have been used in
    completely edentulous as well as partially
    edentulous upper and lower jaws. However, the
    best results have been achieved in treatment of
    the edentulous lower jaw.

17
  • Indications
  • Usually a severely resorbed, completely
    edentulous, lower jaw bone which does not offer
    enough bone height to accommodate Root form
    Implants as anchoring devices.

18
5. Endosteal or Endosseous implant
  • Plate-form implant
  • Blade Implants have a long track record,
    much longer than the Root form Implants. Their
    name is derived from their flat, blade-like (or
    plate-like) portion, which is the part that gets
    embedded into the bone.

19
  • Blade implants are not used too frequently
    any more, however they do find an application in
    areas where the residual bone ridge of the jaw is
    either too thin (due to resorption) to place
    conventional Root form Implants or certain vital
    anatomical structures prevent conventional
    implants from being placed. Nowadays, if a
    certain area of the jaw bone is too thin and has
    undergone resorption due to tooth loss it is
    recommended to undergo a Bone grafting procedure,
    which re-establishes the lost bone, so that
    conventional Root form Implants can be placed.

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Ramus-frame implant
  • Ramus-frame Implants belong in the
    category of endosseous implants, although their
    appearance might not suggest that at first.
  • These implants are designed for the
    edentulous lower jaw only and are surgically
    inserted into the jaw bone in three different
    areas the left and right back area of the jaw
    (the approximate area of the wisdom teeth), and
    the chin area in the front of the mouth.
  • The part of the implant that is visible
    in the mouth after the implant is placed looks
    similar to that of the Subperiosteal Implant.

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Ramus-frame implant
  • Indications
  • Usually a severely resorbed, edentulous
    lower jaw bone, which does not offer enough bone
    height to accommodate Root form Implants as
    anchoring devices. These implants are usually
    indicated when the jaws are even resorbed to the
    point where Subperiosteal Implants will not
    suffice anymore.

24
  • An additional advantage that comes with
    this type of implant is a tripodial stabilization
    of the lower jaw. A jaw as thin as the one shown
    above can easily fracture at its thinnest part.
    The Ramus-frame Implant, once integrated (after a
    three month waiting period) will also stabilize
    and protect the jaw somewhat from fracturing.

25
The Ramus-frame Implant usually comes in a
standard pre-shaped form and needs to be
custom-fitted to the patient's individual jaw
dimension, as shown below
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Ramus-frame implant
27
  • Root form implant
  • Since the introduction of the
    Osseointegration concept and the Titanium Screw
    by Dr. Branemark, these implants have become the
    most popular implants in the world today.

28
  • Root form Implants come in a variety of
    shapes, sizes, and materials and are being
    offered by many different companies worldwide.
    Some clinicians regard them to be the Standard of
    Care in Oral Implantology.
  • These implants can be placed wherever a
    tooth or several teeth are missing, when enough
    bone is available to accommodate them. However,
    even if the bone volume is not sufficient to
    place Root form Implants, Bone grafting
    procedures within reasonable limits should be
    initiated, in order to benefit from these
    implants.

29
  • Root form implant shape
  • Other variations dwell on the shape of the Root
    form implant. Some are screw-shaped, others are
    cylindrical, or even cone-shaped or any
    combination thereof.

30
  • Today, the most accepted material for dental
    implants is high grade Titaniumeither CP
    Titanium or an alloy thereof. The titanium alloy
    implants tend to be stronger than the CP titanium
    implants. The bone integration shows no
    difference to the two different types of
    titanium.
  • Some implants have an outer coating
    of Hydroxyapatite (HA). Other implants have their
    surface altered through plasma spraying, or
    beading process. This was developed to increase
    the surface area of the titanium implant and,
    thus, in theory, give them more stability. These
    surface treatments were also offered as an
    alternative to the HA coatings, which on some
    implants have shown to break loose or even
    dissolve after a few years.

31
Transosseous implant
  • These implants are not in use that much
    any more, because they necessitate an extraoral
    surgical approach to their placement, which again
    translates into general anesthesia,
    hospitalization and higher cost, but not
    necessarily higher benefits to the patient.
  • In any case, these implants are used
    in mandibles only and are secured at the lower
    border of the chin via bone plates. These were
    originally designed to have a secure implant
    system, even for very resorbed lower jaws.

32
The two attachments
long screw posts
The plate
  • A typical Transosseous Implant. The plate
    on the bottom is firmly pressed against the
    bottom part of the chin bone, whereas the long
    screw posts go through the chin bone, all the way
    to the top of the jaw ridge inside the mouth. The
    two attachments that will eventually protrude
    through the gums can be used to attach an
    overdenture-type prosthesis.

33
Osseointegration
  • Definition
  • A time-dependant healing process
    where by clinically symptomatic rigid fixation of
    alloplastic materials is achieved, and
    maintained, in bone during functional loading.
    (Zarb Albrektson,1991)

34
Factors affecting osseointegration
  • Implant biocompatibility
  • Implant design
  • Implant surface
  • Implant bed
  • Surgical technique
  • Loading condition

35
Implant biocompatibility
  • Materials used are
  • Cp titanium (commercially pure titanium)
  • Titanium alloy (titanium-6aluminum-4vanadium)
  • Zirconium
  • Hydroxyapatite (HA), one type of calcium
    phosphate ceramic material
  • Osseointegration interface
  • Osseointegration
  • Biointegration

36
Implant design (root-form)
  • Cylindrical Implant
  • Some investigators explain the lack of
    bone steady state by overload due to
    micromovement of the cylindrical design, whereas
    others incriminates an inflammation/infection
    caused particularly by the very rough surfaces
    typical for these types of implant.
  • Threaded Implant
  • In contrast, Threaded implants have
    demonstrated maintenance of a clear steady state
    bone response.
  • To enhance initial stability and increase surface
    contact, most implant forms have been developed
    as a serrated thread.

37
Implant surface
  • Pitch, the number of threads per
    unit length, is an important factor in implant
    osseointegration. Increased pitch and increased
    depth between individual threads allows for
    improved contact area between bone and implant.
  • Moderately rough surfaces with 1.5µm
    also, improved contact area between bone and
    implant surface.
  • Reactive implant surface by anodizing
    (Oxide layer) ,acid etching or HA coating
    enhanced osseointegration

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Bone Quality
According to Lekholm and Zarb.,1985
  • Quality I
  • Was composed of homogenous compact
    bone, usually found in the anterior lower jaw.
  • Quality II
  • Had a thick layer of cortical bone
    surrounding dense trabecular bone, usually found
    in the posterior lower jaw.
  • Quality III
  • Had a thin layer of cortical bone
    surrounding dense trabecular bone, normally found
    in the anterior upper jaw but can also    be seen
    in the posterior lower jaw and the posterior
    upper jaw.
  • Quality IV
  • Had a very thin layer of cortical
    bone surrounding a core of low-density
    trabecular bone, It is very soft bone and
    normally found in the posterior upper jaw. It
    can also be seen in the anterior upper jaw.

40
Surgical technique
  • Minimal tissue violence at surgery is
    essential for proper osseointegration.
  • Careful cooling while surgical drilling is
    performed at low rotatory rates
  • Use of sharp drills
  • Use of graded series of drills
  • Proper drill geometry is important, as
    intermittent drilling.
  • The insertion torque should be of a moderate
    level because strong insertion torques may result
    in stress concentrations around the implant, with
    subsequent bone resorption.

41
Loading condition
  • Delayed loading
  • A tow-stage surgical protocol
  • One-stage surgical protocol
  • Immediate loading
  • Immediate occlusal loading (placed within 48
    hours postsurgery)
  • Immediate non-occlusal Loading (in single-tooth
    or short-span applications)
  • Early loading (prosthetic function within two
    months)

42
Biomechanics of osseointegrated implant.
  • In all incidences of clinical loading,
    occlusal forces are first introduced to the
    prosthesis and then reach the bone implant
    interface via the implant. So far, many
    researchers have, therefore, focused on each of
    these steps of force transfer to gain insight
    into the biomechanical effect of several factors
    such as
  • Force directions and magnitudes,
  • Prosthesis type,
  • Prosthesis material,
  • Implant design,
  • Number and distribution of supporting implants,
  • Bone density, and
  • The mechanical properties of the bone-implant
    interface.

43
Dental Implant Treatment Planning and Types of
Dental Implants
  • How many teeth are missing?
  • What is the degree of bone loss?
  • Are the remaining teeth in a good position and do
    they have a long-term prognosis?
  • What does the patient expect for an end result?
  • What treatment will result in the best cosmetic
    outcome?
  • What is the patient's budget?

44
  • Overall...
  • What is the most
    practical and feasible implant treatment that
    will produce optimal chewing function and optimal
    cosmetic results in a timely and affordable
    manner?

45
Super structure
  • It could be defined as a metal framework that
    fits the implant abutments and provides retention
    for the prosthesis. Recently, it is defined as
    the superior part of multiple layer prosthesis
    that includes the replaced teeth and associated
    structures

46
Diagnosis and Treatment Planning
  • The evaluation of a patient as a suitable
    candidate for implants should follow the same
    basic format as the standard patient evaluation,
    although some areas require additional emphasis
    and attention
  • Medical History.
  • Psychological Status.
  • Dental History.

47
I. Medical History
  • The patients medical history may
    reveal a number of conditions that could
    complicate or even contra-indicate implant
    therapy. These include
  • Bleeding disorders Pagets disease A history of
    radiation therapy in the maxilla or mandible
    region Uncontrolled diabetes Epilepsy that
    presents with more than one grand mal seizure per
    month
  • In addition, there are a host of systemic medical
    conditions, including steroid therapy,
    hyperthyroidism, and adrenal gland dysfunction
  • Substance abuse including tobacco and alcohol

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II. Psychological Status
  • If the patient cannot come to terms
    with the possibility of failure, or four to six
    months of potential discomfort and inconvenience,
    then he or she is not a suitable candidate for
    implant therapy.

49
III. Dental History
  • It is also vital to evaluate the
    patients chief complaint, as it may have an
    equal bearing on treatment outcome.
  • For example, the treatment plan
    recommended to the patient desiring a more secure
    lower denture will be quite different from the
    one proposed to the patient seeking a fixed and
    rigid appliance.

50
Implant Guidelines
  • Diagnostic phase
  • Problem list treatment considerations
  • -radiographic analysis
  • surgical analysis
  • esthetic analysis

51
Implant Guidelines
  • Diagnostic phase
  • radiographic analysis
  • surgical analysis
  • esthetic analysis

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Implant Guidelines
  • Diagnostic phase
  • radiographic analysis
  • periapical pathology
  • radiopaque/radiolucent regions
  • adequate vertical bone height
  • adequate space above inferior alveolar nerve or
    below maxillary sinus

53
Implant Guidelines
  • Diagnostic phase
  • Problem list treatment considerations
  • radiographic analysis
  • adequate interradicular area
  • bone quality quantity
  • radiographs - panoramic and periapical (CT
    scan or tomography - as indicated)

54
Implant Guidelines
  • Diagnostic phase
  • radiographic analysis
  • radiographs - aid to determine amount of space
    bone available
  • CT (computed tomography) scan - gives more
    accurate reliable assessment of bone (quality,
    quantity width) locale of anatomic structures

55
Implant Diagnostic Guidelines
  • Diagnostic phase
  • radiographic analysis -
  • radiographic stent - (can double as surgical
    stent)
  • acrylic stent with lead beads or ball -bearings
    (5mm) placed in proposed fixture locations
  • allows more accurate radiographic interpretation

56
Implant Guidelines
  • Treatment planning phase
  • Problem list treatment considerations
  • surgical analysis -
  • implant length/diameter
  • determined by quantity of bone apical to
    extraction site
  • use longest implant safely possible
  • diameter dictated by corresponding root anatomy
    at crest of bone

57
Implant Guidelines
  • Treatment planning phase
  • Problem list treatment considerations
  • surgical analysis
  • treatment options
  • immediate - place implant at time of tooth
    extraction
  • delayed immediate - 8-10 week delay
  • delayed - 9-10 months or longer
  • immediate will not allow bone resorption, but
    delayed allows bone fill for stabilization

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Implant Guidelines
  • Treatment planning phase
  • Problem list treatment considerations
  • surgical analysis
  • proper surgical technique during implant
    placement is critical
  • minimal heat generation important

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  • Treatment planning phase
  • Problem list treatment considerations
  • radiographic analysis
  • surgical analysis
  • esthetic analysis

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  • Treatment planning phase
  • Problem list treatment considerations
  • esthetic analysis
  • implant emergence profile
  • restored implant should appear to grow or
    emerge from the gingiva
  • very natural desirable in appearance

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  • Treatment planning phase
  • Problem list treatment considerations
  • esthetic analysis
  • smile line - high in maxilla low in mandible
  • lip shape - full Vs. thin
  • existing ridge defect - if visible with high
    smile line will need augmentation

62
The superstructure for completely edentulous
patients can be classified as follows
  • Implant retained removable overdenture
  • Implant supported removable overdenture
  • Fixed detachable prosthesis (Hybrid prosthesis)
  • Implant supported Fixed Bridge
  • 1) Screwed-in Fixed Bridge
  • 2) Cemented Fixed Bridge

63
Design Concepts for Removable Implant
Prostheses
Resilient
Rigid
  • Removable options can now be
    either nonrigid (resilient) or rigid. A removable
    rigid overdenture will function in a similar
    manner as a fixed implant prosthesis.

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Resilient Design
  • Removable implant prostheses can be
    restored using a combined implant-retained
    and soft tissue-supported overdenture (ie, the
    two- implant overdenture).
  • Fabrication of this type of
    restoration can be completed using individual
    unsplinted retainers that allow rotation or a
    bar-clip prosthesis equipped with a hinging
    mechanism for rotation. The use of a bar (ie,
    Dolder bar-joint) allows movement between the two
    components.
  • In either case, the classic
    principles of complete denture fabrication apply
    adequate denture base extension and proper
    adaptation are essential. These design concepts
    should not be extrapolated to the maxillary arch.

65
Rigid Design
  • The implant-retained and implant-supported
    removable overdenture (ie, multiple implant bar
    overdenture with three or more implants) may or
    may not require the same number of implants as
    the fixed and usually has multiple retentive
    elements.
  • This type of prosthesis does not, however,
    contain a rotational device. The bar used in
    these types of restorations is a bar unit (ex,
    Dolder bar-unit). It allows no movement between
    the bar and sleeve.

66
Treatment Plan Selection
  • Treatment planning and the decision-making
    process is a balance between the patients
    preferences, finances and clinical factors.
  • Understanding that cost is an initial barrier to
    case acceptance, a large percentage of patients
    may reject more expensive options that only
    include fixed prostheses.

67
Clinical factors
  • Quality, quantity, and shape of supporting
    alveolar bone.
  • The cantilever design can be avoided if the
    implants are placed posterior to the foramen. A
    fixed option could be utilized but will display
    less teeth, while a removable option will provide
    increased tooth display. .
  • A patient who has the bone quality to support a
    fixed prosthesis could also be a candidate for an
    implant overdenture supported by fewer implants.

68
Extraoral Diagnostic Guidelines
69
Intraoral Diagnostic Guidelines
70
Implant-overdenture
The most common line of treatment
71
Treatment Planning Determinants
  • 1. Changes in Oral Structures in Edentulism
  • 2. Posterior Ridge Anatomy
  • 3. Occlusal Forces
  • 4. Quality, Location and Quantity of Bone
  • 5. Implant Size
  • 6. Implant Location
  • 7. Arch configuration
  • 8. "Mapping" the Mandible
  • 9. Cantilevering

72
1. Changes in Oral Structures in Edentulism
  • With successive denture treatments,
    it is common for the vertical dimension of
    occlusion to decrease as bone resorbs. This
    promotes an increased tendency toward a skeletal
    Class III relationship.

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2. Posterior Ridge Anatomy
  • Posteriorly, poor ridge height, inadequate
    attached gingiva and compromised ridge shape
    cause increased horizontal movement of the
    prosthesis. This increases the lateral forces
    that are brought to bear on the anterior
    implants, and will affect bar and prosthesis
    design.

74
Posterior Ridge Anatomy
75
3. Occlusal Forces
  • The maximum bite force of subjects with a
    mandibular denture supported by implants is 60 to
    200 higher than that of subjects with a
    conventional denture
  • Edentulous patients that are predisposed to
    clenching and bruxing may be given the necessary
    "tools" to begin parafunctional habits once the
    implant bar is secured in place.

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Occlusal Forces Attachments
77
4. Quality, Location and Quantity of
Bone
  • The minimum buccal-lingual thickness of
    osseous tissue required to successfully place an
    implant is 5 mm.
  • In order to achieve a 5.0 mm "flat" base,
    either the anterior ridge crest peak must be
    removed or a bone graft must be considered.

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5. Implant Size
  • The greater the surface area of the
    implant-bone system, the less concentrated the
    force transmitted to the crest of bone at the
    implant interface. Similarly, the greater the
    surface area of the implant-bone system, the
    better the prognosis for the implant.
  • For each 0.25 mm increase in diameter, the
    surface area of a cylinder increases by more than
    10 per cent
  • For each 3.0 mm increase in length , the surface
    area of a cylinder increases by more than 10 per
    cent.

79
Implant Size
0.25 mm diameter 3.0 mm length
80
6. Implant Location
  • Ideally, occlusal forces should be directed along
    the long axis of the implants. Therefore ,The
    angle of the osseous ridge crest is a key
    determinant of implant angulation.
  • the distance between an implant and any adjacent
    "landmark" (natural tooth or another implant),
    which should be not less than 2.0 mm.

81
The angle of the osseous ridge crest is a key
determinant of implant angulation.
82
7. Arch configuration
  • Mandibular arch forms may be classified as
    tapered or square.
  • With tapered arch forms, the most posterior right
    and left implants in a four-implant treatment are
    often placed well around the "turn" of the arch,
    creating a "U" shaped design that is well suited
    to cantilevering,
  • With a square arch, the four implants are usually
    placed in a relatively straight line. This
    "straight line" bar design is not well suited to
    cantilevering.

83
8. "Mapping" the Mandible
  • The anterior symphysis can be divided into five
    geographic sites
  • A point, 6.0 mm anterior to each mental foramen,
    determines the most posterior boundaries, right
    and left.
  • Another possible implant location occurs at the
    midline.
  • Two additional sites are chosen on each side of
    the midline, spaced equidistantly between the
    midline and the respective distal sites.

84
" Mapping" the Mandible
85
9. Cantilevering
  • The number of implants, their respective lengths
    and locations, the quality of bone support, the
    posterior ridge anatomy, occlusal forces, and the
    opposing dentition are of greater importance in
    determining the appropriate cantilever than a
    suggested formula.
  • One method is to draw a line through the most
    anterior implant, and another through the two
    most posterior implants. The distance between the
    two lines can then be measured. A suggested
    maximum cantilever would be 1.5 times this
    distance.

86
The distance between the two lines can then be
measured. A suggested maximum cantilever would be
1.5 times this distance.
87
Cantilevering
88
Treatment Planning
  • When all the diagnostic information has been
    assembled, a variety of available treatment
    options must be assessed
  • 1. One-Implant Overdenture
  • 2. Two-Implant Overdenture
  • 3. Three-Implant Overdenture
  • 4. Four-Implant Overdenture
  • 5. Five-Implant Overdenture

89
One-Implant Overdentures
  • Indications
  • The maladaptive or dissatisfied denture patient
    who demands greater stability and oral comfort,
  • Elderly patients desiring a more stable
    mandibular denture,
  • Or, as a minimal implant treatment objective for
    the partially edentulous patient with severely
    compromised teeth in which removal would convert
    a patient to a fully edentulous state

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. Two-Implant Solitary Overdenture
  • In the two-implant over-denture, an attachment is
    used to greatly enhance the retentive potential
    of what is essentially a tissue-supported
    prosthesis.
  • If only two implants are placed, which are 13mm
    long or longer, and they are in dense bone, they
    can be left as individual supporting units with
    little risk.

92
Two-Implant Solitary Overdenture
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2. Two-Implant Bar Overdenture
  • If the two implants are 10 mm long or shorter, or
    the bone quality is compromised, then ideally
  • They should be splinted.
  • They should be at least 10 mm apart (in order to
    allow room for a clip or fastening mechanism)
  • They should be no further than 18 mm apart in
    order to limit bar flexure.

95
Two-Implant Bar Overdenture
96
Two-Implant Bar Overdenture
97
3. Three-Implant Overdenture
  • The three-implant overdenture is still
    essentially a tissue-supported prosthesis with
    enhanced retention supplied by the attachment/bar
    complex.

98
Three-Implant Over-denture
99
4. Four-Implant Overdenture
  • At this level, the prosthesis begins to
    derive a larger part of its support and retention
    from the implant/bar complex, and the importance
    of tissue support decreases.
  • Also, the attachments selected for a four-implant
    bar over-denture can be more rigid, as the
    torquing forces generated by the prosthesis will
    be better tolerated.
  • This number allows for some "insurance" in case
    one implant fails to integrate.

100
Unsplinted Implant Overdenture
101
Implant-Bar Overdenture
102
5. Five-Implant Overdenture
  • At this level, a prosthesis can be fabricated
    that is completely implant supported and
    retained, if the AP spread of the implants is
    adequate.
  • The decision to fabricate a bar
    over-denture over five implants, rather than a
    fixed detachable restoration, usually relates to
    the patients ability to maintain proper oral
    hygiene.

103
Five-Implant Overdenture
104
Five-Implant Overdenture
105
PROSTHETIC PROTOCOL
  • Overdenture abutments were cemented or scrowed
    into the implants.
  • Pressure indicating paste was placed on each
    overdenture ball.
  • The denture was seated so that the pressure
    indicating paste could mark the exact location of
    the overdenture abutments. Then, a recess was cut
    into the denture at each abutment location
  • The resulting depressions in the mucosal aspect
    of the denture were lined with polyvinylsiloxane
    material and seated in the patient's mouth.
  • The denture was either lined with a lab-processed
    material or O-rings were used for retention.

106
Overdenture abutments were cemented or scrowed
into the implants.
107
Pressure indicating paste was placed on each
overdenture ball.
108
Then, a recess was cut into the denture at each
abutment location
109
lined with polyvinylsiloxane material and seated
in the patient's mouth.
110
The denture was either lined with a lab-processed
material or O-rings were used for retention
111
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112
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