Module 1 | Session 2 - PowerPoint Presentation

Module 1 | Session 2Treatment planning and restoring the single posterior implant Disclaimer:Some products may not be regulatory cleared/released for sales in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability Please note: It is encouraged that the presentation at hand is adapted and enhanced by clinical cases of the lecturer. Please feel free to adjust the slides according to your preferences.

2 Gain proficiency in diagnosis and treatment planningMaster the restorative steps for a posterior dental implantTransform restorative decision-making and execution into a simple and easy process Learn how to avoid or manage complications Learn how to gain patient acceptance for dental implant treatment Module 1: Course objectives Treatment planning and restoring the single posterior dental implant

3 Dental implants – the standard of careIndications and contraindications for dental implantsCement vs. screw-retained restorationsOptions for replacing a missing tooth Diagnosis and treatment planning Clinical examples How to find patients and gain treatment acceptance Session 1 Session 2 Review of restorative options Surgical templates Biomechanics and occlusion in implant dentistryCase presentation from participantsTreatment plan and case work-up with facultyIntroduction for surgical preparation Time:3 hours Time:3 hours Module 1: Session overview

4 Impression techniquesCement vs. screw-retained restorationsProvisionalizationNobelProcera Restorative workshop and hands-on Patient treatment status Basic patient communication concepts Session 3 Session 4 Avoiding or managing complications Dental implant maintenance Final case presentations Time: 3 hours Time:3 hours Module 1: Session overview

Module 1 | Session 2Agenda Review restorative optionsSurgical templatesBiomechanics and occlusion in implant dentistry

6Restorative solutions for dental implants Implant supported solutions from single tooth to full arch restorations Single posterior implant Full arch implants Multiple implants Single anterior implant

7Restorative solutions for dental implants Implant supported solutions from single tooth to full arch restorations Single posterior implant

8Single missing tooth Restorative options for a single posterior implant: Clinical cases courtesy of Dr. Baldwin Marchack , Pasadena, USA

Single missing toothSingle posterior implant Clinical case courtesy of Dr. Sebastian Horvath, Jestetten, Germany

10Single missing tooth Restorative options for a single posterior implant: Pre-fabricated abutment, cement-retained crown Individualized abutment, cement-retained crown Screw-retained crown (one piece)

11Single missing tooth Screw-retained restorationCement-retained restoration Single posterior implant Photographs courtesy of MDT Claus-Peter Schulz, Baden-Baden, Germany

12Single missing tooth Individualized (CAD/CAM) abutment Pre-fabricated abutment Cement-retained restoration Photographs courtesy of Dr. Baldwin Marchack , Pasadena, USA Photographs courtesy of MDT Claus-Peter Schulz, Baden-Baden, Germany

13Guidelines for abutment selection Issues to be considered: Implant-abutment connectionDistance from the implant platform to bone crestInterocclusal distance Depth of peri-implant soft tissues Biotype of the tissueEmergence profile Shape and contour of the tissue Screw-retained/cement-retained

14 Ideal gingival height – 1 to 3mm, flat shape Ideal interarch dimension – 5 to 10mm Guidelines for abutment selection

15 Guidelines for abutment selection Too deep, not flat – use another solution .

16Guidelines for abutment selection A case study: “Resistance to dislodgement of zirconia copings cemented onto titanium abutments of different heights.” Abbo B, Razzoog M, Vivas J, Sierraalta M. J Prosthet Dent 2008; 99: 25-29 Purpose: Authors measured the force it takes to dislodge a cemented crown on abutments of various heights Results: The taller the abutment height the greater the force required to dislodge a cemented crown. Study recommends that abutments should be no less than 4mm in height when using a cemented crown. Abutment height: 6.5mm 5.5mm Average dislodgement force: 198.09N 124.89N

17Guidelines for abutment selection 2-3mm gingival height 5mm interarch dimension

18Posterior abutment decision tree –single implant crown Posterior Abutment Decision Tree © Copyright 2010 Baldwin Marchack, DDS. Used by permission. Interarch distance > 5mm Interarch distance < 5mm Screw-retained crown Individualized one-piece restoration NobelProcera Screw-retained crown (Ti or Zr) Single posterior implant restoration

19Guidelines for abutment selection Limited interarch dimension Photographs courtesy of Dr. Baldwin Marchack , Pasadena, USA

20Guidelines for abutment selection Use a screw-retained crown:Limited interarch dimensionPatient is a bruxer Retrievability is desired Cement-free solution wanted Screw-retained crown: NobelProcera screw-retained crown GoldAdapt abutment

21Guidelines for abutment selection Photographs courtesy of MDT Claus-Peter Schulz, Baden-Baden, Germany

22Guidelines for abutment selection Clinical case courtesy of Dr. Sebastian Horvath, Jestetten, Germany

23Posterior abutment decision tree –single implant crown Posterior Abutment Decision Tree © Copyright 2010 Baldwin Marchack, DDS. Used by permission. Interarch distance > 5mm Interarch distance < 5mm Cement-retained crown Screw-retained crown Flat tissue < 3mm ID 5–10mm Pre-fabricated abutment Snappy Abutment Individualized one-piece restoration NobelProcera Screw-retained crown (Ti or Zr) Retrievability is desired Single posterior implant restoration

24Guidelines for abutment selectionIdeal gingival height (1–3mm) Ideal interarch dimension (5-10mm)Flat tissue architecture Clinical case courtesy of Dr. Sebastian Horvath, Jestetten, Germany

25Snappy™ Abutment Ideal gingival height (1–3mm)Ideal interarch dimension (5-10mm)Flat tissue architecture Clinical case courtesy of Dr. Sebastian Horvath, Jestetten, Germany

26Clinical case courtesy of Dr. Sebastian Horvath, Jestetten, Germany Snappy™ Abutment

27Posterior abutment decision tree –single implant crown Posterior Abutment Decision Tree © Copyright 2010 Baldwin Marchack, DDS. Used by permission. Interarch distance > 5mm Interarch distance < 5mm Cement-retained crown Screw-retained crown Flat tissue < 3mm ID 5–10mm Pre-fabricated abutment Snappy Abutment Individualized one-piece restoration NobelProcera Screw-retained crown (Ti or Zr) Scalloped < 4mm ID 5–10mm Pre-fabricated abutment Esthetic Abutment (Ti) Procera Esthetic Abutment (Zr) Single posterior implant restoration

28Pre-fabricated Esthetic Abutment Pre-fabricated, customizable Titanium abutment: Comprehensive selection of different margin designs and angulations minimize chair-side adjustments Scalloped margin designed to profile natural soft tissue contours Optional temporary coping available for temporization Indications: Single- and multiple-unit implant restorations Cement-retained Esthetic Abutment (Titanium)

29Esthetic Abutment Clinical case courtesy of Dr. Christopher Marchack , Pasadena, USA

30Esthetic Abutment Clinical case courtesy of Dr. Christopher Marchack , Pasadena, USA Milled titanium Can be adjusted by the lab Corrects minor angulation problems Fixture level impressionEasy to cement

31Posterior abutment decision tree –single implant crown Posterior Abutment Decision Tree © Copyright 2010 Baldwin Marchack, DDS. Used by permission. Interarch distance > 5mm Interarch distance < 5mm Cement-retained crown Screw-retained crown Flat tissue < 3mm ID 5–10mm Pre-fabricated abutment Snappy Abutment Individualized one-piece restoration NobelProcera Screw-retained crown (Ti or Zr) Scalloped < 4mm ID 5–10mm Pre-fabricated abutment Esthetic Abutment (Ti) Procera Esthetic Abutment (Zr) Scalloped or flat tissue > 4mm ID > 5 mm Individualized abutment NobelProcera Abutment (Ti or Zr) Single posterior implant restoration Depending on clinical situation and preference, the GoldAdapt Abutment can be a flexible solution for both cement- and screw-retained restorations and for various gingiva heights.

32Guidelines for abutment selection Individualized abutmentScalloped tissue architectureThick soft tissue Angled implant placement Excessive interarch dimensionExcessive interproximal dimension Fabrication options: NobelProcera abutment in Titanium or Zirconia GoldAdapt abutment

33NobelProcera® abutment NobelProcera Angulated Screw Channel abutmentEasy access due to tilted access holeClinical case courtesy of Dr. Sebastian Horvath, Jestetten, GermanyPhotographs courtesy of MDT Claus-Peter Schulz, Baden-Baden, Germany

34NobelProcera® abutment Clinical case courtesy of Dr. Sebastian Horvath, Jestetten, GermanyPhotographs courtesy of MDT Claus-Peter Schulz, Baden-Baden, Germany

35Posterior implant restorationClinical case courtesy of Dr. Sebastian Horvath, Jestetten, Germany

36Posterior abutment decision tree –single implant crown Interarch distance > 5mm Interarch distance < 5mm Cement-retained crown Screw-retained crown Flat tissue < 3mm ID 5–10mm Pre-fabricated abutment Snappy Abutment Individualized one-piece restoration NobelProcera Screw-retained crown (Ti or Zr) Retrievability is desired Scalloped < 4mm ID 5–10mm Pre-fabricated abutment Esthetic Abutment (Ti) Procera Esthetic Abutment (Zr) Scalloped or flat tissue > 4mm ID > 5 mm Individualized abutment NobelProcera Abutment (Ti or Zr) Posterior Abutment Decision Tree © Copyright 2010 Baldwin Marchack, DDS. Used by permission. Single posterior implant restoration Depending on clinical situation and preference, the GoldAdapt Abutment can be a flexible solution for both cement- and screw-retained restorations and for various gingiva heights.

Diagnosis and prosthetic treatment planning Four important toolsDiagnostic models Radiographs (CB)CT scans NobelClinician Software

Diagnostic ModelsEvaluate: Centric relation position Edentulous ridge relationship to adjacent teeth, opposing ridge, opposing dentitionInclination, rotation, extrusion, alignment of the remaining dentition Soft tissue, gingival heights, and other esthetic parameters Interarch space Determine: Options for occlusal schemes Ideal number and location of implants Direction of forces to which future implants would be subjected 38

Please bear in mind that radiographs are not completely accurate RadiographsEvaluate: Amount of bone available (2D only) Angulation of adjacent teeth Location of anatomical structures Sinus, mandibular canal, mental foramen 39 Clinical case courtesy of Dr. Richard Sullivan, Pasadena, USA

(CB)CT scans40 Clinical case courtesy of Dr. Christopher Marchack, Pasadena, USA Since radiographs are not completely accurate, a (CB)CT scan can improve the diagnosis

NobelClinician® Software41 Visualize the patient’s (CB)CT data together with theintra-oral situation and the diagnostic setup thanks toNobelClinician’s SmartFusion ™ technology Clinical case courtesy of Dr. Christopher Marchack , Pasadena, USA

Surgical templatesModels, radiographs and (CB)CT scans are essential in fabricating surgical templates for various types of surgery:Flapless Mini flapFlap All options are covered with the NobelClinician Software and NobelGuide 42

Surgical templatesBenefits of surgical templates:More precise placement of implantsPreservation of anatomic structures Shorter treatment times, surgery timesLess invasive, flapless surgery and therefore less chance of swellingLess post-operative strain on dentist and patient 43 Manikandan R et al. Implant surgical guides: From the past to the present. J Pharm Bioallied Sci 2013;5(Suppl 1):S98-S102

One integrated treatment workflow, countless benefits44 Clinical diagnostics and treatment acceptance Capturing both the current and desired situation Treatment planning and patient communication Production of surgical template Implant placement either freehand or using pilot drill template or fully guided template Prosthetic design Production of prosthesis Restoration placement NobelConnect ® Clinical diagnostics & treatment acceptance Capturing both the current & desired situation Treatment planning & patient communication Production of surgical template Implant placement Design of final restoration Production of prosthesis Restoration placement

45Treatment planning What is the minimum space needed between teeth for a single-tooth implant? ø 3.5mm ø 4.3mm ø 5.0mm ~1.5mm on each side of implant, 2mm is better for soft tissue Ø 4.3mm 1.5-2mm 1.5-2mm 1.5-2mm Illustrations refer to Nobel Biocare implants with Conical Connection 1 Gastaldo JF et al. Effect of the Vertical and Horizontal Distances Between Adjacent Implants and Between a Tooth and an Implant on the Incidence of Interproximal Papilla. J Periodontol 2004;75(9):1242-1246

46Occlusion and biomechanics The picture shows which force occurs during a situation of malocclusion The resulting force is perpendicular to the plane of contact If the resulting force is too strong for the crown, the restoration may break or may result in crestal bone loss The principles are the same for both natural teeth and implants → how can breakage and crestal bone loss be avoided? Forces acting during a condition of malocclusionIllustrations obtained through internet research:http://www.scielo.br/img/revistas/bdj/v16n1/a08fig01.gif

47Occlusion and biomechanics Uneven loading Overloading may occur because of incorrect placement of the implant and critical restoration geometries This can result in uneven force distribution on the implant's surface Dental implants should ideally be placed so that the biting forces are directed straight downward onto the dental implant

48Occlusion and biomechanics F Bite a 1 F N1 F Nx1 F Bite a 2 F N2 F Nx2 The steeper the line of contact, the stronger the resulting force The force necessary to equalize the vertical bite force is higher, when the line of contact is steeper In the dental environment, the occlusion should be shallow or flat in order to reduce the lateral forces impacting on the occlusion → it is recommended to create shallow or flat occlusion lines to reduce the overload risk

Possible consequences of overloadCrestal bone lossDislodged restorations Screw looseningScrew fracturingRestoration or ceramic fracturePeri-implantitisImplant failure 49 Occlusion and biomechanics Clinical case courtesy of Dr. Baldwin Marchack , Pasadena, USA * This list makes not claim to be complete.

Possible consequences of overload 50 Occlusion and biomechanics Clinical case courtesy of Dr. Baldwin Marchack , Pasadena, USA

SummaryKeep cusp inclines flat or shallow to minimize lateral forcesNo premature contactsLight occlusal contactsAvoid supra-occlusal axial and lateral loadingKeep contacts in the same line as the long axis of the implant, i.e., as close to the center as possibleAvoid cantilevers, whether mesial, distal, buccal , or lingual 51 Occlusion and biomechanics Chia-Chun Yuan J, Sukotjo C. Occlusion for implant-supported fixed dental prostheses in partially edentulous patients: a literature review and current concepts. J Periodontal Implant Sci 2013;43:51-57 Rani G, Gambhir A. Occlusion In Implants - A Review. Indian J Dental Sci 2012;3(4):95-98

52 Refer your patient to your surgical specialist for implant treatmentEnsure a complete patient documentation for later case presentationYou may invite your dental laboratory technician to participate in session 3 of the Esthetic Alliance Program Your next steps for session 3 Treatment planning and restoring the single posterior dental implant

53Thank you! Disclaimer:Some products may not be regulatory cleared/released for sales in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability© Nobel Biocare Services AG. All rights reserved.