Screw versus cement for implant prosthesis installation part 2
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The document discusses the advantages of intra-oral cementation for implant prosthesis installation, highlighting how improved control of excess cement can enhance the fit and safety during the process. It delves into factors like margin design and developing a custom abutment to mitigate issues related to excess cement and maintain periodontal health. The text emphasizes the importance of using modern techniques and materials, including the 'cement control system,' to optimize the cementation process and reduce potential complications associated with excess cement in implants.
Screw versus cement for implant prosthesis installation part 2
- 1. Screw Versus Cement For Implant Prosthesis Installation. Part 2: The Game Changer that tips the balance in Favour of Intra-oral Cementation. Emil L.A. Svoboda PhD, DDS, Published to www.ReverseMargin.com November 12, 2015 1
- 2. What if we could make intra-oral cementation safer??? 2 Then we could, at least, achieve an optimal fit of the implant-abutment junction at the deep tissue level! Would that idea tip the scales in favour of Intra-oral Cementation for you and your patients???
- 3. What do we understand about intra-oral cementation??? 3 1. It is a hydraulic event 2. Excess cement is difficult to control 3. It can go deep into the subgingival environment 4. It can be difficult to detect and remove 5. It can be a longstanding risk factor for periodontitis and peri-implant disease Thomas G Wilson Jr. The Positive Relationship Between Excess Cement and Peri-implant Disease: A Prospective Clinical Endoscopic Study. J. Periodont 2009;1388-1392 The Influence of the cementation margin position on the amount of undetected cement. A pro-spective clinical study. Tomas Linkevicius et al. Clinical Oral Implants Research. Vol 24,Issue 1, 71-76, Jan 2013. Cementation in Dental Implantology. An Evidence Based Guide. Edited by Chandur P.K. Wadhwani. Published by Springer 2015.
- 4. New Information about the Dynamics of Intra-Oral Cementation 4 1. Effect of Margin Design 2. Identifying the “Gingival Effects” 3. Overcoming the Gingival Effects by Design 4. Reducing Cementation Pressure to increase Cement Control Controlling Excess Cement During The Process of Intra-oral Prosthesis Cementation: Overcoming the Gingival Effects. ELA Svoboda, OralHealth Oct 2015;52-66.
- 5. 1) Effect of Margin Design 5 A Chamfer Margin Reverse Margin Tapered Margin B Figure 1 A—Shows 3 aluminum rods with different margin designs. B—Shows the rods with zirconia crowns cemented into place. The arrows indicate the direction of the margins and the cement flow. Note, the Tapered and Chamfer Margin designs direct the cement downwards while the Reverse Margin directs the cement upwards.
- 6. 1) Effect of Margin Design 7 Enter Gingiva! Large amount of Subgingival Cement.
- 7. 2) Gingival Effects Discovered! 8 Figure 8—A Shows 3 aluminum rods with 3 different margin designs that are 1 mm below the top of the clear Tygon tubes (gingiva) The black electrical tape was placed 1 mm below the margin and is 0.125 mm thick. It fills the space between the tube and the rod. The black arrows indicate the direction of the margins. B—Depicts the zirconia crowns cemented into place. Note the huge amount of sub-margin cement, regardless of margin design. A Chamfer Margin Reverse Margin Tapered Margin B
- 8. 2) Gingival Effects 10 WHEN A CROWN IS LARGER THAN ITS RETAINER, AND WHEN IT MAKES A SEAL WITH THE PERI- IMPLANT GINGIVA PRIOR TO BEING SEATED …… EXCESS CEMENT CAN GET TRAPPED BETWEEN THE GINGIVA AND THE CROWN UNDERSURFACE. THE CROWN CAN THEN ACT LIKE A “PLUNGER” THAT PUSHES THE TRAPPED CEMENT FURTHER INTO THE PERI-IMPLANT SPACE.
- 9. 2) “Gingival Effects” are comprised of at least 4 Effects 11 1. Deflection Effect 2. Eddy Effect 3. Plunger Effect 4. Bellows Effect These are described in greater detail in: Controlling Excess Cement During The Process of Intra-oral Prosthesis Cementation: Overcoming the Gingival Effects. ELA Svoboda, OralHealth Oct 2015;52-66 and are demonstrated in videos at www.ReverseMargin.com.
- 10. This cemented implant crown was removed because of chronic “Food Impaction” 12 “X-ray is clear of visible cement. A hole was drilled into the crown to access the retaining screw for removal.”
- 11. Residual Cement is not a Myth It is a Problem! 13 Loose piece of cement placed back onto crown Undersurface of abutment with biological debris
- 12. Residual cement can be hard and smooth and difficult to detect 14 red arrow shows residual acrylic cement
- 13. Beware of the “Gingival Effects” Excess cement is difficult to locate, access, and remove ……. because the prosthesis may block access to effective instrumentation. “Better to schedule surgery to locate and remove excess cement! 15
- 14. Poor Cement Control Many implants today still have almost straight walled standard abutments that are designed for intra-oral preparation and cementation “It would be difficult to avoid subgingival cement injection” 16 Figure from “Dental Implant Prosthetics, Carl E. Misch, Elseier Mosby, 2005 Pg 445
- 15. 3) Overcoming the Gingival Effects by Design 17 Narrow Crown Hybrid Crown Wide Crown A B Figure 9—A Shows 3 aluminum rods with Reverse Margins that terminate 1 mm below the top of the clear Tygon tubes (gingiva). The black electrical tape was placed at the margin and is 0.125 mm thick. It fills the space between the tube and the rod. There are 3 crown designs, wide, narrow and hybrid. The narrow is smaller in diameter than the tube, and the hybrid has a narrow part sub-gingival tapering to a wider profile 1/2 mm above the tube. B—Depicts the crowns cemented into place. Note the huge amount of sub-margin cement under the wide crown, while the narrow and hybrid crowns did not have any cement that breached the black tape border.
- 16. 3) Overcoming the Gingival Effects by Design A “Well Designed” Custom Abutment Controls: 1. Emergence profile – to support shape of the base of the prosthesis 2. Margin height – to specifically control the margin position (Supra-, Equi-, up to 1 mm Subgingival) 3. Margin design – use Reverse Margin™ Design and avoid tissue facing margins 4. Margin width – use a horizontal rim to push gingiva away to form a barrier to cement, and allow it to flow out of the tissues 5. Material – Titanium, hybrid Titanium/Zirconia - for biocompatibility and aesthetics A “Well Designed” Custom Prosthesis Controls: 1. Emergence profile – that works with the custom abutment to allow excess cement to move out of the tissue spaces during the process of intra-oral cementation 2. Margin Design – to compliment abutment margin and to direct excess cement out of the tissue space 3. Material Composition – to meet aesthetic needs of the pateint 19
- 17. Custom Abutments should Stretch the surrounding gingiva Stretching adjacent gingiva creates a barrier against excess cement intrusion 20 Stretched Gingiva X-section of Standard abutment X-section of Custom abutment Loose gingiva
- 18. The Well Designed Custom Abutment Stretches the Gingiva Stretching the peri-implant gingiva creates a tighter seal that can further resist excess cement injection The Reverse Margin Design makes the custom abutment even better, by changing the direction of the excess cement ejection away from the soft tissue 21 Note the blanching of the tissues – yellow arrows
- 19. Look at Custom Abutments from a premium abutment company These are designed with limited control from dentists Margins are positioned subgingival, even where this is not necessary for aesthetics They have tissue facing margins They are much narrower than the emergence profile crowns that will be cemented onto them (cause Gingival Effects) 22 These Abutments have Poor Cement Control Features!
- 20. These custom abutments are Poor Choice for Cement Control! Not much better than a Stock Abutment below, available at “no cost” from another implant company. During cementation, neither system will control projection of cement into the peri- implant space, or prevent the “Gingival Effects” Where is the value in these custom abutments ???? 23
- 21. Abutment Types Simple Stock Pre-shaped Stock UCLA Base-Cast Custom Milled Milled Base Yes Yes Yes Yes Distorted by Casting Processes No No *Yes No Margin type Downwards Downwards/ Sideways **Controlled **Controlled Prevents Gingival Effects by Design No No **Yes **Yes Optimized Implant- Abutment Connection Yes Yes *No **Yes 24 *The UCLA base is distorted by high temperatures during the casting and removal of investment material **The Reverse Margin Design and Cement Control Design are Patent Pending … available through licensed Labs . Core3D Centres are licensed in Canada and the USA. Info at www.ReverseMargin.com
- 22. 4) Reducing Cementation Pressure Dentists use Huge Insertion Pressure to cement crowns and bridges into the mouth. This behavior is evolved from use of older cements with poor compression, retentive, solubility and handling properties. Hard Biting 600 N Finger Pressure 40 N * Low Pressure 2.5 N ** Super Low Pressure 0.125 N *** 25 * Effects of finger pressure applied by dentists during cementation of all-ceramic crowns. M.Zortuk M. et al, Eur J Dent 2010, Oct; 4(4):383-388. **Low force cementation. Wilson PR. J Dent. 1996 Jul;24 (4):269-73. *** Super Low Cementation Forces. Emil L.A. Svoboda PhD, DDS, Video Published to www.ReverseMargin.com, July 13, 2015.
- 23. How is it Possible … To Reduce Cementation Pressure so Much?? With the Cement Control System™ and a modern dual cure, fluid acrylic based cements, it is not necessary to overcome tight contacts and resistance from gingiva … and do all of this under the added pressure of time, to avoid premature setting of cement. Everything has already been tried in and confirmed .. Fit good, Contacts good, Occlusion good …. Clean and dry, gently tap the prosthesis into place … light cure for 4 seconds per side and start cleaning away excess cement .. Its so easy. Much better control over the whole cementation process! 26 1. Super Low Cementation Forces. Emil L.A. Svoboda PhD, DDS, Video Published to www.ReverseMargin.com, July 13, 2015. 2. Prosthesis Installation Technique using the Reverse MarginTM Design and Technique. Emil L.A. Svoboda, Published to www.ReverseMargin.com. June 16, 2015.
- 24. The Cement Control System™ includes Super Low Installation Pressure Installation 27
- 26. Teflon is easy to place and remove and blocks ingress of cement 29
- 27. Immediate Implant, Cover came off, Custom Cover placed 2nd Stage 30
- 28. Received Prosthesis - Sterilzed & Bagged. Nice and Clean! 31
- 29. Install Custom Abutment, Fit OK?, Torque, Teflon, Lubricate, Cement, Remove Excess, Maintain … Great Control of Excess Cement! 32
- 30. Screw or Cement?? The Cement Control System™ Makes Intra-oral Cementation BETTER Because it 1) Controls Excess Cement 2) Optimizes the Implant-Abutment Connection 3) Avoids Cantilevers Created for Screw Access 33
- 31. USE THE REVERSE MARGIN™ AS PART OF YOUR CEMENT CONTROL SYSTEM™ TO PROTECT THE FOUNDATIONS OF YOUR PROSTHETIC TREATMENT Go to www.ReverseMargin.com to view videos and other supporting information 34
- 32. We Partnered with a Large Precision Milling Group to Create Custom Components for the “Cement Control System™” 35 Workflow – Your Lab or Diamond Dental Studio receives your models and/or digital impressions and sends files to Core 3 D Centres for Design and Precision Milling. Your Lab or Diamond Dental Studio then assembles and further customizes work for delivery to Your Office and your Patients. Contact us at www.ReverseMargin.com North America Making It Available
Editor's Notes
- #31: A Systematic Review of Screw- versus Cement-Retained Implant-Supported Fixed Restorations, Sami Sherif et al, J of Prosthodontics Vol 23, 2014 1-9. Conclusions – no difference in major or minor problems – cementation failure and fracture of porcelain – what type of cement, what was the material supporting the porcelain. Both cemented and screwed prosthetics have a screwed element. The Positive Relationship Between Excess Cement and Peri-Implant Disease: A Prospective Clinical Endoscopic Study Thomas G. Wilson Jr.*, J Periodontol 2009;80:1388-1392. Excess dental cement was associated with signs of peri-implant disease in the majority (81%) of the cases. Clinical and endoscopic signs of peri-implant disease were absent in 74% of the test implants after the removal of excess cement. If these findings are confirmed by other studies, they argue for increased diligence in cement removal at the time of cementation, as well as arousing suspicion of excess cement when signs of peri-implant disease are seen. In all cemented cases, due diligence should be paid to removing all excess cement at the time of placement of the fixed partial denture. The delay in the appearance of peri-implant disease is particularly troubling and indicates that cemented implant prostheses should be evaluated periodically for peri-implant disease. Four types of cement were used from five manufacturers (Table 1) Resin modified glass ionomers, zinc polycarboxylate, resin cement, Glass ionomer. Within the scope of this study, no difference could be detected in the initial presence of disease or response to treatment based on the type of cement used to lute the restoration. Peri-implant disease was first diagnosed in the test implants loaded from 4months to >9 years after ementation of the single-unit fixed partial dentures. a surgical flap procedure eliminated signs of inflammation after 1 month in most (25 of 33) of the treated implants. Mombelli A, Mu¨ ller N, Cionca N. The epidemiology of peri-implantitis, Clin. Oral Implants Res. 23(Suppl. 6), 2012, 67–76 doi: 10.1111/j.1600-0501.2012.02541.x © 2012 John Wiley & Sons A/S 67