Preventing Peri-implantitis by Safer Prosthesis Installation
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The document discusses methods for preventing peri-implantitis, emphasizing the importance of proper installation techniques for dental prosthetics. It compares screw versus cement installations, highlighting that cement-in techniques may reduce risks associated with misfit and biological complications. The findings suggest that many dental implants suffer from issues related to installation inadequacies, which can lead to various peri-implant diseases.
Preventing Peri-implantitis by Safer Prosthesis Installation
- 1. Preventing Peri-implantitis by Safer Prosthesis Installation OCTOBER 5, 2017 EMIL L.A. SVOBODA PHD, DDS HONORED FELLOW, AMERICAN ACADEMY OF IMPLANT DENTISTRY, DIPLOMATE, AMERICAN BOARD OR ORAL IMPLANTOLOGY/IMPLANT DENTISTRY 1
- 2. 2 Milan Jovanovic RDT Digital Workflows 1(888)337-5223 www.DiamondDentalStudio.com Acknowledgements Vladimir Agranat PhD Fluid Mechanics 1(416)708-7153 www.acfda.org Helping Deepen my Knowledge of Laboratory Technology and Making Custom Prosthetics Helping Deepen my Knowledge of Fluid Dynamics and Modeling Technology
- 3. 1. Improve function 2. Reduce collateral damage 3. Increase load bearing units and thus preserve remaining teeth 4. Preserve load bearing tissues 5. Immune to caries Why were natural teeth lost? Function and Pathogenic Oral Microbes 3 Dental Implants Let Us Put Humpty Together Again After All Else Has Failed
- 4. Why are Dental Implants Lost? Function and Pathogenic Oral Microbes Unlike Teeth – Dental Implants are NOT FREE Treatment Complications are Bad for Business 4
- 5. 4 Large Reviews 2013 - 15 Mucositis 30% of Implants Peri-implantitis 15% of Implants Peri-implant Disease 45% of Implants Failures 4% 5 years, 8% 10 years Same for Cement or Screw Installation Atieh MA et al. The Frequency of Peri-implant diseases: A systemic review and meta-analyses. J Periodontol 2013:84(11):1586-1598 Whittneben et al. Clinical Performance of Screw- Versus Cement Retained Fixed Implant-Supported Reconstructions: A Systemic Review. The Int J Oral Maxillofac Implants; 2014:29(Suppl):84-98. Sherif S et al. A Systematic Review of Screw- versus Cement-Retained Implant Supported Fixed Restorations. J of Prosthodontics 2014 (23)1-9 Daubert DM et al. Prevalence and predictive factors for peri-implant disease and implant failure: a cross-sectional analyses. J Periodontol 2015:86(3): 337 5 S C Safety
- 6. Screw Vs Cement for Dental Implant Prosthesis Installation Part 1: The Logic Behind the Argument. Emil LA Svoboda, Published to www.ReverseMargin.com, Update January 2, 2016 Screw versus Cement for Implant Prosthesis Installation. Part 2: The Game Changer the Tips the Balance to Favour Intra-oral Cementation. Emil LA Svoboda, Published to www.ReverseMargin.com, Update January 2, 2016 6Should We Install Implant Prosthetics by Screw or Cement? Which is Safer for our Patients? Can We Do Better? S C 45% Peri-Implant Disease Insanity … Doing the same thing over and over and expecting different results. Albert Einstein
- 7. Why do We Need to Adjust Contacts, Fit & Occlusion to Install it into the Mouth? Why is Fit Variable? Whether Created from Physical and/or Digital Impressions The Lab Makes the Prosthesis To Fit on a Model of the Mouth 7
- 8. The BIG Problem with Screwed-in Prosthetics Inaccurate Model The Abutment-Prosthesis Complex is Joined Together on an Inaccurate Model Inaccuracy is Variable and Very Hard to Assess by Both the Lab and the Dentist 8
- 9. Abutment-Prosthesis Complex is Made to Fit the Model and Joined Together Built on Inaccurate Model (±100 µm) *Optimized Laboratory Technician makes Abutments and Prosthesis fit Inaccurate Model and Joins them Together Implant 2 Analogue Built on Inaccurate Model (±100 µm) *Optimized *Optimized for Implant Analogue Abutment- Prosthesis Complex *Optimized to Fit Inaccurate Model and Joined Implant 1 Analogue Prosthesis Abutment Abutments Joined to Inaccurate Prosthesis have Inaccurate Relative Position And Alignment Abutment Abutment Prosthesis Abutment Dentist removes the Screw-Abutment-Prosthesis Complex from an Inaccurate Model to Install into the Mouth 9 Joined on Model Lab Model Inaccuracy Determines the Size of the Prosthesis-Abutment Misfit / Macrogap 3-D Position Inaccurate
- 10. SIZE MATTERS! Pathology is a Result of: Host Resistance Size of Inoculum Pathogen Virility Screw-in Technique Creates Misfits and Stress at the Implant-Abutment Connection Screw-in Installation Creates Misfits at the Deep Tissue Level Misfits are Difficult to Fix Mechanical Problems • Misfit of Components • Distortion of Parts • Movement of Parts • Broken Retaining Screws Biological Problems • Stress on Bone • Voids at interphase and Microbial Invasion Implant 1 In Mouth Optimized *Misfit Implant 2 In Mouth Abutments are joined to Prosthesis 10 Stressed Parts Misfi t Stress on Bone
- 11. The Dreaded Macrogap AKA – Implant-Abutment Misfit Top factors leading to dental implant abutment/implant fixture misfit: The dreaded microgap. Scott Froum, Editorial Director, Feb 6, 2017 Clinical Associate Professor – Periodontist NYU “When bacteria are able to colonize a Macrogap, implant failure can result due to biologic failure such as peri-implantitis. (4) In addition, misfit can lead to mechanical failure of the implant system because of factors such as screw fracture and/or implant fracture. (5)” Caused by: 1. Inaccurate impressions/Model Distortion 2. Tight Contacts 3. Tissue Interferences 4. Cheaper Inaccurate Parts 5. Use of Engaging Abutments 6. Trying to Re-insert an Abutment that has been Previously Misfit (Implant-Abutment Distortion) 11
- 12. Risk Factors and Risk Stratification Using a Risk Score for Peri-implant Pathology Attributable fractions, modifiable risk factors and risk stratification using a risk score for peri-implant pathology. M Nobre ….. Paulo Malo … Jan 2017 Journal of Prosthodontic Research, Vol 61, Issue 1, 43-53 www.for.org/en/treat/peri-implant-pathology-risk-assessment/take 1.History of Periodontitis 2.Is there Bacterial Plaque Present 3.Implant Close to other Teeth or Implants 4.Prosthetic Materials 5.Lack of Passive Fit or Prosthetic Loosening 6.Existing Bone Level 7.Smoking Patient 12
- 13. How Did They Detect Macro-gaps? Their Xrays are Insufficient! Table 3 Attributable Percent of Peri-implant Pathology History of Periodontitis 74% Non-Optimal Screw Joint 5% The Example is assembled in the mouth! Passive Fit in Screw Retained Multi-unit Implant Prosthesis Understanding and Achieving: A Review of the Literature. M.M.Buzaya and N.B. Yunus. J Indian Prosthodont Soc. 2014, Mar;14(1):16-23 – An Elusive Goal! Attributable fractions, modifiable risk factors and risk stratification using a risk score for peri-implant pathology. M Nobre ….. Paulo Malo … Jan 2017 Journal of Prosthodontic Research, Vol 61, Issue 1, 43-53. How Can We Detect Macro-gaps? 13
- 14. Risk Factors and Risk Stratification using a Risk Score for Peri-implant Pathology History of Periodontitis X X X X X X X X Bacterial Plaque Present X X X Bleeding on Probing X X X X Lack of Passive Prosthesis Fit X X X X X X X Patient Smokes X X X Negative Points 4 7 7 9 9 11 11 11 Risk Level M H H VH VH VH VH VH Low Risk (L) <10% 6 Months Moderate Risk (M) 10-20% 4 Months High Risk (H) 20-40% 3 Months Very High Risk (VH) >40% 2 Months How Does One Diagnose, Maintain or Treat An Implant-Abutment Misfit / Macrogap? Attributable fractions, modifiable risk factors and risk stratification using a risk score for peri-implant pathology. M Nobre ….. Paulo Malo … Jan 2017 Journal of Prosthodontic Research, Vol 61, Issue 1, 43-53. https://www.for.org/en/treat/peri-implant-pathology-risk-assessment/take 14
- 15. *Acceptable Levels Model Error of 150 µm Passive Fit could not be achieved with Screwed-in Prosthetics! *Review: Passive Fit in Screw Retained Multi-unit Implant Prosthesis Understanding and Achieving: A Review of the Literature. M.M.Buzaya and N.B. Yunus. J Indian Prosthodont Soc. 2014, Mar;14(1):16-23 Comparison of the Accuracy of Different Transfer Impression Techniques for Osseointegrated Implants. Zen BM et al. JOI Vol 41 No 6 2015: 662-667 Tissue -integrated prostheses. Branemark PI, Zarb GA, Albrektsson T. Chicago: Quintessence; 1985. p. 253 Figure of implants above from “Dental Implant Prosthetics, Carl E. Misch, Elseier Mosby, 2005 & 2015 Even the theoretical suggestion of “not more than 10 microns error” by PI Branemark in 1985, could be considered sloppy as Periodontal Pathogens are around 1 micron in diameter Mechanical and Biological Instability Comparing the accuracy of master models based on digital intra-oral scanners with conventional plaster casts. C Vogtlin et al. Physics in Medicine. June 2016. Volume 1, 20–26 15
- 16. Multiple Unit Screwed-in Prosthetics AMPLIFY the Implant-Abutment Misfit Problem! Figure of implants from “Dental Implant Prosthetics, Carl E. Misch, Elsevier Mosby, 2015 Pg 740 Dental Implant Prosthetics. Carl Misch, 2nd Edition, Elsevier-Mosby, 2015,Ch 28. Passive Fit in Screw Retained Multi-unit Implant Prosthesis Understanding and Achieving: A Review of the Literature. M.M.Buzaya and N.B. Yunus. J Indian Prosthodont Soc. 2014, Mar;14(1):16-23 – “Passive Fit is an elusive goal!” Bacterial leakage of different internal implant/abutment connections. Nasar HI and Abdalla M. Future Dental Journal 2015 Why Do We Need a Specific Screw Tightening Sequence for Multiple Implants? 16
- 17. Effectiveness of Implant Therapy Analyzed in a Swedish Population: Prevalence of Peri-implantitis Derks et al. J Dental Research, 2016 Vol 95(1):43-49 (588 patients with 2,277 implants ) Patients with 4 or more implants were 15X more likely to have Peri-implantitis 77% of these prosthetics were installed by the Screw-in Technique 17
- 18. Derks J, Tomasi C. Peri-implant health and disease. A systematic review of current epidemiology. J Clin Periodontol 2015; 42 (Suppl. 16): S158–S171. Department of Periodontology, Institute of Odontology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden Meta-analyses weighed mean prevalence per Implant Peri-implant mucositis 43% Peri-implantitis 22% Peri-implant Disease 65% 1. Peri-implant Diseases are common complications 2. Clinicians should inform their patients prior to treatment 3. Clinical strategies should include preventative measures 18 Effectiveness of Implant Therapy Analyzed in a Swedish Population: Prevalence of Peri-implantitis. Editorial by Emil L.A. Svoboda. www.ReverseMargin.com. 2016
- 19. Jepsen S et al. Primary Prevention of peri-implantitis: Managing of peri-implant mucositis. J Clin Periodontol 2015;42 (Suppl. 16) S152-S157 Primary Prevention is of Key Importance “at present no established and predictable concepts for the treatment of peri-implantitis” (for Screwed in Prosthetics?? - ES) Correct fit of implant components Access for regular diagnosis & hygiene If cemented, keep margins supragingival 19
- 20. “Primary Prevention is of Key Importance” “Preventing Peri-implantitis by Managing Mucositis” Primary Prevention??? BUT …….. You Cannot Clean or Correct Implant-Abutment Misfit The Misfit / Macrogap PROBLEM Can be Prevented by Intra-oral Cementation! Jepsen S et al. Primary Prevention of peri-implantitis: Managing of peri-implant mucositis. J Clin Periodontol 2015;42 (Suppl. 16) S152-S157 S Sahin and MC Cehreli. The Significance of Passive Framework Fit In Implant Prosthodontics: Current Status. Implant Dent 2001;10 85-92 20
- 21. The Intra-Oral Cementation Technique 21 1. Abutments are Attached to Implants Individually 2. No tight contacts to keep the abutments from seating 3. Implant-Abutment fit depends on Manufacturing Accuracy, Not Model Accuracy The Big PROBLEM relates to Understanding and Control of this Important Process Implant-Abutment Connections are Optimized!
- 22. The Current Cement-in Technique Abutments are Individually installed onto implants already in the Mouth Implant 2 In Mouth *Optimized Fit Implant 1 In Mouth Abutment Abutment Abutments Installed Onto Intra-Oral Implants Individually Implant-Abutment Fit is Determined by Manufacturing Specifications Lab does NOT JOIN the Prosthesis to Abutments 22 Prosthesis Made to Fit Inaccurate Model Implant- Abutment Fit is Optimized
- 23. Prosthesis is Adjusted and Luted to Abutments Intra-orally after the Implant-Abutment Connection is Optimized for Fit and Stability 23 Abutments are Individually installed onto implants already in the Mouth Implant 2 In Mouth *Optimized Fit Implant 1 In Mouth Cement-in Prosthesis Optimizes the Implant-Abutment Fit Cement Space Allows for a Passive Fit of the Prosthesis Implant 2 In Mouth Built on Inaccurate Model (±100 µm) Misfit/Cement Filled *Optimized Fit Excess Cement Is a Problem! Excess Cement Can be Removed, BUT Can it be Prevented? Implant 1 In Mouth Abutments are Independent Prosthesis Cemented to Abutments Abutment and Screw Fit Optimized Possible Open Margins, Residual Subgingival Cement and Prosthesis Misalignment Problems Like Margin Overhangs or Under Extensions
- 24. Cementation in Dental Implantology. An Evidence Based Guide. Edited by Chandur P.K. Wadhwani. Published by Springer 2015. Many “Screwers” Focus ONLY on Residual Cement! and Are Unaware/Choose to Forget the Serious Misfit / Macrogap Problem! Many “Cementers” Deny Cementation Related Problems! What is Another Big Problem? 24 Change is Necessary to Prevent Complications
- 25. Nissan et al. Long-Term Outcome of Cemented Versus Screw-Retained Implant-Supported Partial Restorations. Int J Maxillofac Implants 2011; 26:1102-1107 Split Mouth Design, 38 patients, 221 Implants, mean follow up 5 years to 15 years 25 Cement-in Can be Safer than Screw-in Prosthesis Installation S C Safety
- 26. Relationship of Residual Excess Cement to Peri-implant Disease Cemented Single Implant Retained Crowns -39 consecutive patients referred to the Periodontist had 42 implants with peri-implant disease -12 of the same patients had 20 implants without disease and without detectable subgingival cement -34 of 42 diseased cases (81%) had Residual Subgingival Cement After Cement Removal 25 of 33 (74%) no longer has signs of peri-implant disease after 30 days (74% of the 81% = 60%) Thomas G Wilson Jr. The Positive Relationship Between Excess Cement and Peri- implant Disease: A Prospective Clinical Endoscopic Study. J. Periodont 2009;1388 26
- 27. There is a Predictable Treatment for Peri-implant Disease for Cemented Cases! 74% of the Peri-implant Disease Cases Healed When Residual Subgingival Cement was Removed Single Tooth Cemented Restorations Thomas G Wilson Jr. The Positive Relationship Between Excess Cement and Peri-implant Disease: A Prospective Clinical Endoscopic Study. J. Periodont 2009;1388-1392 27
- 28. Preventing Residual Subgingival Cement could reduce Peri-implant Disease by 60%! Albert Einstein “Intellectuals Solve Problems, Geniuses Prevent them.” Treatment of Complications Can be Very Expensive! 28 (74% X 81% = 60%) S C Safety
- 29. Excess cement 1. can be difficult to control** 2. can go deep into the subgingival spaces*,** 3. can be difficult to detect and remove** 4. is a risk factor for periodontitis and peri-implant disease*** 5. can be removed by endoscopic means or after surgical access*** What do we understand about intra-oral cementation? It is a hydraulic event.* 29 *Cementation in Dental Implantology. An Evidence Based Guide. Edited by Chandur P.K. Wadhwani. Published by Springer 2015. **The Influence of the cementation margin position on the amount of undetected cement. A prospective clinical study. Tomas Linkevicius et al. Clinical Oral Implants Research. Vol 24,Issue 1, 71-76, Jan 2013. ***Thomas G Wilson Jr. The Positive Relationship Between Excess Cement and Peri-implant Disease: A Prospective Clinical Endoscopic Study. J. Periodont 2009;1388-1392
- 30. What Determined the Margin Design for Replacement Teeth? Design of Margins Reflected OLD Technology Feather Margin – soft gold at the thin margins were burnished towards the tooth retainers to form a seal. Chamfer & Butt – responded to the needs of porcelain and the availability of the high speed. The older cements also require high pressure installation to overcome back pressure caused by the small cement space necessary to reduce film thickness and compensate for their low compressive strength and solubility at the margins. 28
- 31. Margin Design Effects the Direction of Cement Flow! Why Choose Margin Designs that Direct Excess Cement into the Tissues??* 31
- 32. “Gingival Effects” Discovered and Described by Author When “Gingiva” was Present, Excess Cement was Projected Under the Gingiva, Regardless of Margin Design! 32
- 33. The Gingival Effects on Cement Flow Can Be HUGE Controlling Excess Cement During The Process of Intra-oral Prosthesis Cementation: Overcoming the Gingival Effects. ELA Svoboda, OralHealth Oct 2015;52-66 and at www.ReverseMargin.com. They include the 1) Deflection Effect, 2) Eddy Effect, 3) Plunger Effect, 4) Bellows Effect and …. Skinny Abutments with Fat Crowns are the Worst! We All Need to Know Why! 33
- 34. Gingival Effects Can Cause: Residual Subgingival Cement 34 Wider Crown and Higher Seating Force Can Cause Subgingival Cement Excellent Fit on Abutment Biting Force to Seat Crown Abundant Residual Subgingival Cement VN17
- 35. MC 16 Distal-LingualBuccalMesial 35 1) Open Margins 2) Residual Subgingival Cement Gingival Effects Can Cause:
- 36. TN17 LingualMesial Gingival Effect # 5 “Resistance to Displacement Effect” 36 Buccal In Addition to Residual Subgingival Cement, Gingiva Can Contribute to the “Open Margin and Cement Voids”
- 37. Can We Prevent the Gingival Effects and Resulting Complications? 37 BUT Can We Move the Gingiva Out of the Way? Avoid the Use of Stock Abutments When Any Part of the Margin goes Sub-Gingival
- 38. Clinical Experiment 4 – Take Prosthesis Out PE 16 Experiment Experiment Experiment 38
- 39. PE 16 The Process – Supra-Gingival Margins Experiment Treatment 39 ©EmilLASvobodaPhD,DDS
- 40. Experiment 4 Results PE 16 Experiment No Cement Beyond Margins 40
- 41. KL 15-16 Experiment 6 – 2 Splinted Crowns Experiment 41 Margins Subgingival on Buccal
- 42. KL 15-16 Experiment 6 – No Gingival Effects Experiment No Residual Cement Beyond Margin 42 Gingiva Does Not Interact with the Prosthesis – By Design
- 43. WM 16 No Residual Cement Beyond Margin Experiment 43New Version Experiment 7 Expressed Cement Not Removed Gingiva Does Not Interact with the Prosthesis – By Design
- 44. Preventing the Gingival Effects The Well Designed Custom Abutment 1. pushes against the Gingiva to get it out of the way of the prosthesis and 2. creates a relative barrier to excess cement going into the tissue spaces The Well Designed Prosthesis is narrower in the subgingival zone to allow the easy flow of excess cement out of the tissue spaces Intelligent Design makes Installation Easier and Safer and Optimizes the Implant-Abutment Connection 44
- 45. 45 HJ 15 The Designs are Not Limited to Particular Materials
- 46. 46 HJ 15 The Singer - High Esthetics Mouth When Wide Open
- 48. These are Not Sensitive to Gingival Effects Thus Not Safe for Cementation!
- 49. *Retainer Replica Technique Concept: Reduce the amount of cement in the prosthesis to …. Reduce the amount ejected into the subgingival environment Effect of implant abutment modification on the extrusion of excess cement at the crown-abutment margin for cement-retained implant restorations. C. Wadhwani et al. The International journal of oral & maxillofacial implants 11/2011; 26(6):1241-6. Cementing an Implant Crown: A Novel Measurement System Using Computational Fluid Dynamic Approach. C Wadhwani, S Goodwin, K Chung. Clinical Implant Dentistry and Related Research, 2014. *Cemented implant restoration: A technique for minimizing adverse biologic consequences. G Galvan, J Kois, Y Chaiyabutr and D Kois. J Prosthet Dent 2015;114:482-485 *Technique for controlling the cement for an implant crown. C Wadhwani, A Pineyro, Journal of Prosthetic Dentistry. 2009:102;V1; 57 Effects of a Cementing Technique in Addition to Luting Agent on the Uniaxial Retention Force of a Single-Tooth Implant-Supported Restoration: An In Vitro Study. International Journal of Oral & Maxillofacial Implants . Santosa RE, Martin W and Morton D. 2010, Vol. 25 Issue 6, p1145-1152. 49 *
- 50. Cement Voids Under a Prosthesis can be Very Difficult to Detect and Correct Can Cement Volume be Controlled to Avoid Both Overfilling and Underfilling the Prosthesis? Can You Ensure an Even Flow of the Cement Out of the Prosthesis? 50
- 51. Why Do We Cement Restorations? 1) Retention 2) Fill Space to Prevent VOIDS Are VOIDS Dangerous? a) Breading grounds for oral pathogens – top 3 reasons prosthetics on natural teeth fail & can cause periodontal and peri-implant-disease b) Very difficult to detect and treat c) Reduce retention d) Discoloration e) Stink and taste bad Can VOIDS be Prevented? 51
- 52. 1) Off angle forces on a prosthesis affect flow of cement 2) Fingers, teeth and gingiva may obscure visualization of cement flow 3) Tight contacts and gingiva may redirect the seating of a prosthesis The Abutment Replica Technique Can Cause Residual Subgingival Cement and Cement Voids Control of Cement Exiting the Prosthesis Margins Can Be Very Difficult Safer Intra-oral Cementation: Prevention of Cement Voids under the Prosthesis. ELA Svoboda, submitted for Publication JOI Aug 2017 52 © Emil LA Svoboda PhD, DDS
- 53. 1) OVERFILL the prosthesis with cement and extrude excess cement from around the entire margin 2) Apply cement to prevent air entrapment 3) Hold prosthesis down firmly while the cement sets VOIDS can be Very Difficult to Detect and Correct VOIDS CAN BE PREVENTED by Technique! 53 © Emil LA Svoboda PhD, DDS Safer Intra-oral Cementation: Prevention of Cement Voids under the Prosthesis. ELA Svoboda, submitted for Publication JOI Aug 2017
- 54. 54 Resin Cements Can Prevent Voids due to Cement Washout, and Have High Compressive Strength Low Pressure Cementation Requires a Wider Cement Space Solubility Compressive Strength Cement Space Cementation Pressure Zinc Phosphate Cement High Low 30-40 microns 40 NCm Resin Cement Very Low High 80-100 microns 1 NCm
- 55. We Can Make Prosthesis Installation Safer by Preventing: 55 1) Implant-Abutment Misfits / Macrogaps (Use a Safer Intra- oral Cementation & Avoid Current Screw-in Techniques) 2) Residual Subgingival Cement (Avoid Poorly designed Custom and Stock Abutment-Prosthesis Combinations that are insensitive to the Gingival Effects, Stay Supragingival) 3) Cement Voids (Avoid Soluble Cements, Trapping Air Under Prosthesis, Cement Minimization Techniques and High pressure cementation with small cement spaces) 4) Open Margins (Use procedures that are sensitive to Gingiva and tight contacts. Use larger cement spaces) Controlling Excess Cement During the Process of Intra-oral Prosthesis Cementation: Overcoming the Gingival Effects. ELA Svoboda, OralHealth Oct 2015;52-66 and at www.ReverseMargin.com. Prosthesis Installation Technique using the Reverse MarginTM Design and Technique. ELA Svoboda, www.ReverseMargin.com June 16, 2015.
- 56. We Can Make the Screw-in Prosthesis Installation Technique Safer Too! 56 By Preventing the Macrogap!
- 57. Why do Some Clinicians Choose the Screw-in Installation Technique? 1. RETRIEVABILITY 2. Because We Can! Is it Free? 3. *Frustrated by Open Margins and Residual Subgingival Cement Dental Implant Prosthetics: Achieving Retrievability and Reducing Treatment Complications by using a Modified Installation Technique. ELA Svoboda, Oral Health October 2016, pgs 8-20 Hypothesis: Dr. ELA Svoboda – Open Margins are Bad for Business 57 ** *
- 58. Retrievability is NOT Specific to the Screw-in Technique! It is a Result of “Retrievability Features” of the Implant-Abutment- Prosthesis Complex 58
- 59. Retrievability Feature #1 Working Path of insertion parallel alignment of implants and sensitive to alignment remaining teeth Can we really make implants and prosthetics parallel to adjacent teeth and each other in 3 Dimensional Space? a. Yes b. No 59
- 60. Retrievability Feature #2 Do they make it easier to fool ourselves about fit? Are they stable? Multiple Units may require the use of Multi-Unit Abutments to build a little tolerance to off-angle implants for the part that telescopes into the implant (internal hex, taper fit) or abutment (external hex). 60
- 61. Favorable Position of Screw Access Hole Use of special Angled Screw Channel (ASC) Abutment with special screw heads, help make more favorable access hole locations and reduce treatment related cantilevers Sadly …. This Feature DOES NOT PREVENT The Implant-Abutment Misfit Problem with Current Screw-in Technique 61 Retrievability Feature #3
- 62. Retrievability Features can Add Risk and Cost 1. site development procedures $$$$ 2. use of guided implant surgery $$ 3. expensive additional parts and lab work dealing with screw access holes and their maintenance $$$ 4. may create difficult to maintain cantilevers, that are unstable and create space for oral pathogens $$$$ 5. Currently - can cause an implant-abutment misfit $$$$$ Retrievability Features can be expensive! The Dentist must weigh the cost and benefit for each case. 62
- 63. Retrievability Features can Add Risk and Cost Perio-endo issues, smoker, some medical issues TP16 63
- 64. 64 Retrievability requires Sinus Graft No sinus graft advisable TP16
- 65. Non- Retrievable – used Bone Spreading Graft Immediate implants TP16 65
- 67. Retrievability Features can Add Risk and Cost Bridge Non-Retrievable TP16 67
- 68. Reducing the Need for Retrievability 1. Repair hybrid prosthetics - Use durable materials (Zirconia) 2. Control Excess Cement - Use the Cement Control System 3. Tighten Abutment Screws - Optimize the Fit, use engaging abutments, optimize torque (2X), reduce/avoid cantilevers, use genuine parts, use night guards. 4. Gain access to soft tissues under prosthesis - work around prosthesis Retrievability Features are NOT Free! Is it Cost Effective for the Patient? Prosthesis May Still Need to be Replaced 68
- 69. OK - You Have Convinced Your Patient to Buy a Retrievable Screw-in Fixed Restoration. Can you prevent the implant-abutment misfit? YES! 69
- 70. 70 NOT If You JOIN the Abutment-Prosthesis Complex on the Inaccurate Model First! Screw-in Installation Creates Misfits at the Deep Tissue Level Misfits are Difficult to Fix Implant 1 In Mouth Optimized *Misfit Implant 2 In Mouth Abutments are joined to Prosthesis
- 71. Retrievability Features in Place Assembled in Mouth Optimized Implant-Abutment Fit Prosthesis Seating and Excess Cement Removal Facilitated by use of the Cement Control System. Screw access holes are available for easy access on a needs basis. Svoboda Modification 11. Lab delivers abutments and prosthesis separately with … 2. …access holes sealed with acrylic plugs 3. Dentist installs abutments to optimize their fit 4. Access channels are filled with Teflon plugs 5. The prosthesis is cemented into the mouth 6. Excess cement is removed, as well as possible 7. The access holes are drilled out 8. Prosthesis is taken out of the mouth 9. Excess cement removed 10.Assembled Prosthesis is screwed into place 11. Teflon plugs are reinstalled 12.Acrylic plugs are remade 13.Occlusion is adjusted Svoboda Modification – Option 1 71
- 72. Svoboda Modification 2 1. Lab delivers abutments and prosthesis separately with … 2. …access holes sealed with tooth colored acrylic plugs 3. Dentist installs abutments to optimize fit 4. Access channels are filled with Teflon plugs 5. The prosthesis is cemented into the mouth 6. Excess cement is removed 7. The access holes are drilled out 8. Prosthesis is taken out of the mouth 9. Excess cement removed and voids are filled 10.Assembled Prosthesis is screwed into place 11. Teflon plugs are reinstalled 12.Acrylic plugs are remade 13.Occlusion is adjusted 72 Assembled in Mouth Optimized Implant-Abutment Fit Prosthesis Seating and Excess Cement Removal Facilitated by use of the Cement Control System. Screw access holes are available for easy access on a needs basis. Retrievability Features in Place Svoboda Modification – Option 2
- 73. Simplified Svoboda Modification Least Steps and Reduces Service due to the Resin Screw Access Hole Cover 1. Lab delivers sterilized abutments and prosthesis separately with … 2. …access holes sealed with acrylic plugs 3. Dentist installs abutments to optimize fit 4. Access channels are filled with Teflon plugs 5. The prosthesis is cemented into the mouth 6. Excess cement is removed 7. The access holes are drilled out 8. Prosthesis is taken out of the mouth 9. Excess cement removed and voids are filled 10.Assembled Prosthesis is screwed into place 11. Teflon plugs are reinstalled 12.Acrylic plugs are remade 13.Occlusion is adjusted Simplified Svoboda Modification 73 Assembled in Mouth Optimized Implant-Abutment Fit Prosthesis Seating and Excess Cement Removal Facilitated by use of the Cement Control System. Screw access holes can be made for access, on a needs basis. Retrievability Features in Place
- 74. Now We Can PREVENT Implant-Abutment Misfits for Retrievable Prosthetics Too And this can also Reduce Peri-Implant Disease by 60% Svoboda E. Dental Implant Prosthetics: Achieving Retrievability and Reducing Treatment Complications by Using a Modified Installation Technique. OralHealth October 2016, pp 8-18 74 S C Plus 60% More Safety
- 75. In Order to Provide Safer Treatment for Our Patients Safer Installation Protocols that Promise To Reduce Peri-implant Disease by 60% We Need to Implement 75 Reality Our Patients Depend on Us!
- 76. 76 PREVENTION IS BEST Thank You for Your Attention 600+ Implants Restored www.ReverseMargin.com [email protected]