Implant components and basic techniques3

3 . Implant Components History, New Developments and Basic Prosthodontic Procedures George R. Perri DDS Division of Advanced Prosthodontics, Biomaterials and Hospital Dentistry UCLA School of Dentistry

Osseointegrated Implants Implant Components History, New Developments and Basic Prosthodontic Procedures George R. Perri DDS Division of Advanced Prosthodontics, Biomaterials and Hospital Dentistry UCLA School of Dentistry This program of instruction is protected by copyright ©. No portion of this program of instruction may be reproduced, recorded or transferred by any means electronic, digital, photographic, mechanical etc., or by any information storage or retrieval system, without prior permission.

Components Categories Fixtures / Implants Abutments Healing Basic Custom Gold cylinders Analogs / Replicas Abutment Fixture Impression copings Connection Armamentaria Screw drivers Guide pins Original Implant Pillar

Fixture Fixture / Implant Titanium Different Configurations Threaded and Non-threaded Cylindrical and Tapered Different Surfaces Machined Surface Enhanced Surface Different Widths Narrow, Regular and Wide Platforms Different Heads External and Internal Original Br å nemark Style Hex-headed Implant

Fixture Original Threaded Fixture External hex headed Original Brånemark had only a machined surface. Newer versions have an “enhanced” surface. Lengths 7-20 mm in regular platform Widths / Platforms: Narrow: 3.3mm Regular: 3.75 and 4.0 mm Wide: 5mm

New Tri -channel Internal Connection Replace Select 

Replace Implant System Enhanced Surface Two implant designs: Unique anatomic “tooth root” shape Classic cylinder Internal Connection

Replace Select Tapered Implant Immediate placement into extraction sockets Anatomic advantages with taper Ease of achieving initial stability Immediate loading Esthetic restorative components Simplified placement (including staff responsibilities)

Implant Evolution Implant options now include 1.5 and 3.0 mm collars. Implant threading / surface treatment to bottom of collar Newest generation has surface treatment to top of implant: No polished collar.

Four Diameters 3.5mm 4.3mm 5.0mm 6.0mm Replace Select Implants 2.4mm 2.7mm 3.25mm 3.8mm

Straumann implants Standard Plus Standard Tapered Effect

4.1 mm S Ø 3.3 mm RN 3.3 mm 4.8 mm 4.8 mm S Ø 4.1 mm RN 4.8 mm 4.8 mm 4.8 mm 6.5 mm S Ø 4.8 mm RN S Ø 4.8 mm WN Standard implants

Standard Plus implants 3.3 mm 3.5 mm SP Ø 3.3 mm NN 3.3 mm 4.8 mm SP Ø 3.3 mm RN 4.1 mm 4.8 mm SP Ø 4.1 mm RN 4.8 mm 4.8 mm SP Ø 4.8 mm RN 4.8 mm 6.5 mm SP Ø 4.8 mm WN

4.1 mm 3.3 mm 4.8 mm 4.8 mm 4.8 mm 6.5 mm Tapered Effect implants

Straumann ’ s 8° Morse taper connection Proven validity and function since 1986 Loosening torque slightly higher than tightening torque Proven resistance against long-term cyclic loading Standardized tightening torque of 35 Ncm 91% of functional load transferred into Morse taper for optimal load distribution Stability against rotational loosening Sutter et al. 1988/Schroeder et al. 1996/Norton 1997

Morse taper Non-rotation through mechanical lock: 8° or less will yield a mechanically locking friction fit

Morse taper connection Thread only takes 9% of the functional load 8° Morse taper absorbs 91% of the functional load

Prosthetics Regular neck implants and abutments

Solid abutments RN 4.0 mm RN 5.5 mm RN 7.0 mm WN 4.0 mm WN 5.5 mm WN (Wide Neck) RN (Regular Neck)

synOcta ® prosthetic system Abutment selection on the model Implant level impression capability Provisionalization Custom abutment

synOcta ® abutments RN (Regular Neck) WN (Wide Neck)

Indications for Narrow Neck Implants Single tooth replacement Maxilla: lateral incisors Mandible: central/lateral incisors Minimal space (5.0 mm) For screw-retained For cement-retained Abutment Possibilities

Abutments Restorative Abutment allows connection of the restoration to the implant. The many different types of abutments facilitate the restoration of implants.

Maintains an opening through the soft tissue during treatment, allowing easy access to the fixture. Not useable to make the final restoration One Piece Construction: Screw and Abutment in one No Inferior hex Value in polished tapered design. Healing Abutment

Basic Abutments Standard Abutment Titanium Cylindrical Shape Internal hex on bottom matches hex on fixture to prevent rotation. Designed to be supra- gingival and non-esthetic No emergence profile Useful for Hader Bars and FBAB.

Basic Abutments Standard Abutment Lengths 3 to 10 mm Separate Abutment Screw and Abutment Body The gold screw screws into the abutment screw head

Standard Abutment Healing Cap Protects head of abutment during treatment phase. Helps control soft tissue during healing Basic Abutments

Basic Abutments Estheticone Abutment Conical Abutment Titanium Hexed connection to fixture. Collar widths of 1, 2 & 3 mm Improves esthetic potential of restoration.

Basic Abutments Estheticone Abutment Separate Abutment Screw and Abutment Body

Basic Abutments Estheticone Abutment Seating of the abutment must be verified with an x-ray. Design of abutment allows up to 30 ° non parallelism of fixtures

Basic Abutments Estheticone Abutment Healing Caps Protects the head of the abutment during restorative phase Helps control soft tissue During healing During restorative phase keeps tissue from collapsing over the subgingival margin

Basic Abutments Angulated Abutment Titanium Corrects screw access for mal-aligned implants, but doesn’t improve implant loading. Internal 12 positions on bottom matches hex on fixture to prevent rotation and give multiple angle correction possibilities. Can be difficult to use esthetically. Same healing cap / gold cylinder as the estheticone

Basic Abutments MirusCone Abutment Shorter height than Estheticone abutment Allows greater degree of non-parallelism with fixture placement- up to 40 °. MultiUnit Abutment Same dimensions as MirusCone No hex under abutment to facilitate placement Only for bridges Strengthened Abutment Screw 20 º 40 º Allows 40º misalignment NP 1-7mm RP 1-9mm WP 1-7mm

Gold Cylinder Gold Cylinder Different cylinders for different abutments. Cylinders become incorporated into the final restoration Since it is pre-made and with a machined interface toward the abutment, the consistency of fit is improved over a custom casting

Gold Cylinder Standard Abutment Gold Cylinder : 3 and 4 mm heights Held in place by a gold screw. Slotted Hexed Underside is non-hexed: for multiple units “bridges” only . Restoration is waxed and cast around the gold cylinder.

Gold Cylinder Estheticone Abutment Gold Cylinder Only contact is on margin of abutment. Same cylinder is used for angled abutments.

Custom Abutments Custom Abutment Types: UCLA: Gold cylinder to fixture Hexed- Engaging Non Hexed – Non Engaging Set margin with impression cap i.e. the “easy abutment” Prepable Titanium: Cemented final restoration Straight Esthetic Angled Esthetic Ceramic Cemented final restoration Screw retained Procera Titanium Alumina Zirconia Provisional to fixture (acrylic / composite)

Custom Abutments UCLA Abutment Allows connection of the restoration directly to the fixture. Combines abutment, gold cylinder and restoration into one. Uses include: Esthetics Limited Interocclusal space Angulation Correction Custom Substructures

Custom Abutments UCLA Abutment Original UCLA Abutment was a plastic castable pattern. Improved consistency of fit was developed with the introduction of a precast and machined abutment with a waxing sleeve. Two types Hexed / non-rotational for a single tooth Non hexed for bridges

Hexed UCLA Abutment GoldAdapt ™ (engaging) Gold Cylinder to Fixture (engaging) NP/RP/WP Single tooth and multiple unit restorations “ UCLA” type abutment: wax/invest/cast When interarch space is limited When the fixture angulation is not acceptable Follows contours of the soft tissue Conventional restorative technique Hexed Screw-retained & Cemented Restorations Ø3.7mm (NP) Ø4.3mm (RP) Ø5.3mm (WP) .5mm UniGrip Minimum interarch space required: 3.5mm

Multiple unit restorations “ UCLA” type abutment: wax/invest/cast When interarch space is limited Non-Hexed UCLA Abutment GoldAdapt ™ (non-engaging) Gold Cylinder to Fixture (non-engaging) NP/RP/WP Screw-retained Restorations Ø3.7mm (NP) Ø4.3mm (RP) Ø5.3mm (WP) .5mm UniGrip Non-hexed Minimum interarch space required: 3.5mm

UCLA Abutment - Clinical Procedure Custom Abutment -Substructure and One Piece Restoration Bake porcelain directly to Abutment Wax/Invest Gold alloy Casting Optional (Recommended for WP) Screw-retained- One Piece Restoration

UCLA Abutment : Lingual Screw Access

Easy Abutment ‘ Easier than Crown & Bridge’ Available in: 4.3 , 5.0 & 6.0 pre-defined margin get to use an impression coping

Easy Abutment with Healing Cap

Easy Abutment with Screw Access Plug in place - No modification of the Easy Abutment was required in this case.

Easy Abutment Snap-on Impression Cap in place.

Impression material is injected into the Snap-on Impression Cap.

The Snap-on Impression Cap is captured in the impression.

An Easy Abutment Analog may be used if the abutment has not been modified. Note the accurate impression of the sub-gingival margin.

A standard soft-tissue model is fabricated.

Pre-fabricated Plastic Cap Copings may be used if the Easy Abutment has not been modified.

The restoration is completed using standard crown & bridge procedures.

… is cemented in place with ImProv ™ temporary cement.

Titanium Prepable Esthetic ™ NP/RP/WP Single tooth and multiple unit restorations Prepable “pre-machined” titanium abutment Follows contours of the soft tissue Conventional restorative technique Cemented Restorations 15° 11mm 1.4mm NP 2.7mm RP 2.8mm WP 3.2mm 25° 11mm 1.5mm 2.8mm RP only Straight NP 11mm RP 8/11mm WP 8/11mm NP Ø4.5mm RP Ø5 - 7mm WP Ø6 - 8mm

Titanium Prepable Esthetic - Clinical Procedure Abutment prepared on the master cast Optional (Recommended for WP)

Ceramic Esthetic Abutment All Ceramic ™ RP Single tooth and multiple unit restorations All ceramic abutment for optimal esthetics When fixture placement is too coronal When there is thin gingival tissue Preparation follows contours of the soft tissue Conventional restorative technique Screw-retained & Cemented Restorations 6mm 12mm 2mm 4.1mm Now with UniGrip! Torque without deforming Square UniGrip Retentive connection

Ceramic Abutment - Procedure Porcelain baked directly to Abutment Abutment prepared on the master cast Optional Screw-retained Alternative: Porcelain baked directly to abutment

Procera ® Abutment NP/RP/WP Single tooth and multiple unit restorations Custom Titanium abutment Custom Alumina Custom Zirconia Follows contours of the soft tissue Conventional restorative technique Cemented Restorations

Advanced Uses for Custom UCLA ABUTMENTS Custom abutment substructures Separate units Linked units

Custom Abutment Sub-Structures Indications Misaligned implant fixtures Elimination of screw access hole from the occlusal surface Control the thickness of metal and porcelain in an anterior restoration Develop proper emergence profiles

Custom Abutment Sub-Structures A UCLA abutment allows the development of a custom shaped substructure: Separate Units Linked Abutments Can allow the final restoration to be cemented or screw retained (with a lingual set-screw).

UCLA Abutment Custom Sub-Structure: Angle Correction- Lingual set screw

Custom Abutment Sub-Structures: Separate Units Begin with full contour wax-up using a UCLA abutment (AuAdapt). Note the buccal angulation of the implants.

Custom Abutment Sub-Structures: Separate Units Abutments are prepared with a three degree taper. Note the channel prepared for the lingual access retaining set screw.

Custom Abutment Sub-Structures: Separate Units Each abutment is designed to engage the hex on top of the implant fixture. Note the change in angulation created by the abutments. Note lingual set screw channels

Custom Abutment Sub-Structures: Separate Units

Custom Abutment Sub-Structures: Separate Units Final prosthesis in position. These restorations can be either screw or cement retained.

Custom Abutment Substructures: Linked Abutments Supra-structure will fit with confidence intraorally if it fits in the lab More predictable sharing of load between implants Less chance an abutment screw may loosen

Custom Abutment Substructures: Linked Abutments The implants placed in the right mandible were inclined towards the lingual

Custom Sub-Structures: Linked Abutments This technique permits the clinician to control two key occlusal factors – width of the occlusal table, and the cusp angles. Result: Reduced load magnification and less chance of implant overload.

Custom Abutments *Note size of the embrasures *Note width of the occlusal table

Provisionals Provisional cylinders exist which can substitute for all available gold cylinders with conventional abutments. There are also provisional cylinders that attach directly to the fixture like a UCLA abutment.

Provisionals Use of a provisional UCLA abutment allows addition of acrylic for the development of a provisional that connects directly to the fixture without a separate abutment.

Primary Uses: Esthetic Issues Soft tissue Tooth shape / form. Prosthesis design issues . Identify angulation problems that may affect the definitive restoration. Gain patient approval of esthetics/function before investing in final. Provisional Restorations

Analogs / Replicas Analogs allow the accurate transfer of a facsimile of the intraoral component to a working model.

Analogs Abutment Analogs Allows creation of a model with the same characteristics as a given intraoral abutment .

Analogs Fixture Analogs Allows creation of a model with the same characteristics as a given intraoral fixture .

Abutment Level Fixture Level Linked Impression Copings Impression Copings

Impression Copings Abutment Level: Open and Closed Tray Copings A specifically matched coping is needed for each differently shaped abutment.

Impression Copings Open Tray Pick Up Square Are different names for the same type of coping.

Impression Copings Abutment Level : A square coping is “locked” into the impression due to their shape. Screwed to abutment with guide pin. Impression made with “open” tray. Analogs are attached before pouring the master model. Open Tray Pickup Square

Impression Copings Closed Tray Transfer Tapered Are different names for the same type of coping.

Impression Copings Abutment Level: Screw to abutment Take impression with closed tray Remove Impression Unscrew copings Attach to analogs Replace coping into impression and pour. Closed Tray Transfer Tapered

Impression Copings Fixture Level Impression Coping Impression is made directly to the fixture- No abutment is in place. X-ray is always necessary to verify seating Coping can be Open or Closed Tray The fixture level impression is required for a fixture level “UCLA”restoration and for extraoral abutment selection.

Impressions Fixture Level- Open Tray Registers both position of fixture and orientation of the fixture hex. Becomes locked into the final impression so an open tray is needed. After the tray is removed a fixture analog is connected and the model poured

Impression Copings Fixture Level- Closed Tray Shape allows it to remain in mouth when impression is removed-uses a flat head screw giving it a tapered shape Two piece coping will still allow registration of Hex

Impression Copings Fixture Level- Closed Tray Shape allows it to remain in mouth when impression is removed-uses flat head screw Two piece coping will still allow registration of Hex Single piece coping is only for bridges (no hex registration)

Changing Pick-up to Transfer Coping By utilizing the flat head screw instead of a guide-pin , the same impression coping can be used as a closed tray coping instead of an open tray impression coping Pick-up / with guide pin Guide Pin Flat Head Screw

Master Casts How do we know they are accurate?

Castings – Passive Fit DEVELOP A CORRECT MODEL FIRST or Plan to solder after try in of units Reduces risk of implant overload

Impression Copings Linked Copings Long history of use Behaves as pick-up impression coping Accuracy with original techniques limited by materials used

Impression Copings Linked Copings Useful in impression taking to improve accuracy of impression Can be fixture or abutment level Remove index from mouth and pour a registration in quick set intra oral plaster type II before taking final impression.

Impression Copings Linked Copings Useful to prove accuracy of final Impression

Impression Technique 2 Advanced Technique Make a Custom Tray around any model… preferably one that shows the healing abutments. Keep it close to the tissue in the area that the holes for the impression copings are made.

Impression Technique 2 Advanced Technique Replace the healing abutments with the pick up style fixture level impression copings

Impression Technique 2 Advanced Technique Make sure the tray will seat without touching the impression copings Take a regular final impression but remove any impression material from the copings Lute the copings to the tray with GC pattern resin

Impression Technique 2 Advanced Technique Carefully unscrew tray from mouth and add analogs Carefully pour master model

Impression Copings Linked Copings Directly connect the copings intraorally with triad or flowable composite Section and re-lute the copings as necessary Pickup impression

Connection Armamentaria Screw Drivers

Connection Abutment Holders Counter rotation device

Connection Torque Drivers Allow the connection to be made with the correct pre-load

Connection Laboratory Guide Pins Gold screw size Abutment screw size

Selected References Binon P. Implants and components: Entering the new millennium. Int J Oral Maxillofac Implants 15:76-94, 2000

Coming soon Edentulous Mandible – Overlay Dentures Edentulous Maxilla – Overlay Dentures

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Implant components and basic techniques3

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