Consensus Statements and Recommended Clinical Procedures ...

Consensus Statements and Recommended Clinical Procedures ...

IN THE NAME OF GOD 1 Treatment Plans Related to Key Implant Positions and Implant Number Presented by:Dr.Piroz Givehchian Supervised by: Dr. Mansour Rismanchian And Dr.saied Nosouhian Dental of implantology Dental implants research center Isfahan university of mediacal science

2 Treatment Plans Related to Key Implant Positions and Implant Number chapter 8 3 The primary causes of complications in implant dentistry are related to: biomechanics Misch developed a treatment plan sequence to decrease the risk of biomechanical overload, consisting of following:

1. Prosthesis design 2. Patient force factors 3. Bone density in the edentulous sites 4. Key implant positions and number 5. Implant size 6. Available bone in the edentulous sites 7. Implant design 4 when an implant restoration is joined to a natural tooth, an increased risk of :

Abutment screw loosening Implant marginal bone loss Unretained restoration occurs The distribution of occlusal forces is optimized when The Ideal Treatment Plan For A Partially Edentulous

independent implant prostheses are designed Patient Includes An Independent Implant Restoration 5 Four general guidelines 1. Cantilevers on the prosthesis should be reduced and preferably eliminated 2. Three adjacent pontics should not be designed in the prosthesis

3. The canine and first molar sites are key positions,especially when adjacent teeth are missing 4. An arch is divided into five segments. When more than one segment of an arch is being replaced, a key implant position is at least one implant in each segment 6 No Cantilevers

Cantilevers are force magnifiers to the implants, abutment screws, cement or prosthesis screws, and implant-bone interface The length of the cantilever is directly related to the amount of the additional force Cantilevered restoration on multiple implants may be compared with a class I lever 7 Anteroposterior distance

The distance between the last abutment and the farthest abutment from the end of the cantilever represents the resistance arm and may be called the : A-P spread of the implants A-P distance Cantilever arm 8 To enforce the rule of no cantilever

When one or two adjacent teeth are missing one implant per tooth When 3 to 4 adjacent teeth are missing two terminal abutments, one on each end Restorations of 5 to 14 units require additional abutments 9

However, when terminal abutments are not designed in the the treatment plan and a cantilever is planned, so Other force and surface area factors should compensate : The force factors of parafunction Crown height

Masticatory dynamics Implant location Opposing arch A-P distance 10 A-P = 6 to 8 mm A-P = 2 to 5 mm

2.5 times When? Five or more implants positioned around an arch Several plan exists because of the arch form and the splinted implants A-P > 8 mm however More than two pontics are not indicated on the posterior cantilever even under ideal condition

11 When implants are in one plan the cantilever should rarely extend farther than the A-P distance ,regardless of how low the patients force factors 12 When the cantilever on the prosthesis is represented by only a lateral incisor the ideal implant position may not include the lateral incisor position! When a pontic replaces the lateral

incisor the soft tissue drape may be improved compared with an implant. 13 When the force factors are unfavorable: The cantilever length should be reduced or eliminated The implant number should be increased The implant size should be increased The implant design surface areas should be increased 14 No three adjacent ponties

Why?? 1. 2. The adjacent abutments are subjected to considerable additional force The greater the span between abutments, the greater the flexibility of the metal in the prosthesis Is more of a problem for implant than natural teeth because 15

Mobility of teeth Acts as stress absorber Angled force magnify the amount of force(ant maxillary implant should also limit the number of pontic ) 16 17 The span of the pontics in the ideal treatment plan should be limited to the size of two premolars

13.5 to 16 mm When a molar is one of the teeth missing between existing teeth, the missing molar space may be 10 to 14 mm long When the span > 14 mm Two pontics should be considered to replace molarrelated to the missing number Missing tooth span the is often of roots in the mandible and number of buccal roots in the maxilla 18

19 20 Canine and first molar sites A fixed restoration replacing a canine is at greater risk than any other restoration Lateral incisor is one of the weakest teeth The first premolar is often one of the weakest posterior teeth It is contraindicated to replace a canine and two or more adjacent teeth a) 1 , 2 , 3 b) 2 , 3 ,4

Implant restoration c) 3 , 4 ,5 21 Key implant positions 1,2,3 3 , 4 ,5 Cantilever is of limited negative impact: 1.

2. 3. 4. The smallest tooth in the arch The least bite force Canine implant is large No occlusal contact is present on lateral in centricocclusion or excursions 2 , 3 ,4 22 A small-diameter implant may also be used to support the

lateral incisor, and three implants with no cantilever reduce the increased force factor risks 23 1. 2. When the central, lateral, canine, and first premolar are missing, the ideal key implant positions are: The central and first premolar (rule 1, no cantilever) & Canine position (rule 3, the canine and first molar position) 24

When the central, lateral, canine, and first premolar, second premolar, and first molar are missing, the three key implant positions are: 1. The central and first molar sites (Rule 1) & 2. The canine site (Rules 2 and 3, no three adjacent pontic and canine and first molar position) 25 1. 2. When the central, central, lateral, canine, first premolar, and second premolar are missing, there are three key implant positions: The central and second premolar (Rule 1, no cantilever) &

The canine position (Rule 3, the canine and first molar position) 26 When 8 adjacent teeth are missing from second premolar to the opposite canine, there are four key implant positions: 1. The canine and second premolar position (Rule 1) 2. The opposite canine (Rule 3)

One of the central incisor positions (Rule 2) 3. 27 1. 2. 3. When 10 adjacent teeth are missing from second premolar to second premolar, there are five key implant positions: The 2 second premolar sites (Rule 1) & The 2 canine sites (Rule 3) &

One of the central incisor positions (Rule 2) 28 1. 2. When the 4 teeth from the first premolar to second molar is missing , there are three key implant positions : The first premolar and second molar sites (Rule 1) & The first molar position (Rule 3) 29

1. 2. When the patient is missing six adjacent teeth from the central incisors to the first molar, there are three key implant positions: The central and first molar position (Rule 1) the canine position (Rule 3) When a larger implant cannot be inserted into the molar site, an additional implant is required to follow Rule 2 3 pontics Should be

large implant 30 When the patient is missing teeth from first molar to first molar, there are five key implant positions: The two first molars (Rule 1) 2. The two canines (Rule 3) 3. A central incisor (Rule2) 1. Additional implants in the posterior region are indicated when a larger diameter implant is not positioned in the first molar sites (Rule 2) Implants in the second premolar site are also usually indicated when:

1. force factors are moderate or 2. bone density is D3 Even more implant when force factors are severe or bone density is D4 31 1. 2. Missing of second premolar and first molar and second molars, three key implant positions to restore the full

contour of the missing molars : The second premolar and second molar terminal abutments The first molar pier abutment 32 1. 2. 3. Missing of 8 teeth from first premolar to first premolar, there are five key positions: The first premolar sites (Rule 1, Rule 4) The two canines (Rule 3, Rule 4) An implant in one of the central incisor positions (Rule 2, Rule

4) 33 Implant number Additional 1. implants Increase surface area and decrease stress 2. Reduce the cantilever length 3. Reduce the number of pontics in the prosthesis

4. Providing more abutments for greater retention of the restoration 5. Reduced risk of screw loosening or uncemented prosthesis 34 Canine to first molar missing

The two terminal key implant positions are usually inadequate One or two additional implants are required in most clinical situations (depending on patient force factors and bone density) The additional implant of choice is : Second premolar site, especially when a larger-diameter implant is not placed in the molar site 35

Young male who bruxes severely one implant for each missing root (two implants for each molar) Moderate force factors and poor bone density (D4 bone) 36 Mandible From 5 to 9, with at least 4 between the mental foramina

If 7 implant with no two separate restorations may be fabricated cantilever to permit mandibular flexure and posterior torsion 37 Mandible From 5 to 9, with at least 4 between the mental foramina

If < 6 implant prosthesis as a result mandibular flexure a cantilever must be designed in a fixed of the Cantilevers in the mandible should ideally be projected in only one posterior quadrant to increase the A-P distance and reduce the force to the implants When implants are positioned in four of the five open pentagon positions in the mandible, a cantilever is at a reduced risk of overload because of: 1. Favorable dynamics of an arch 2. Increased large A-P distance

3. Favorable bone density 38 Maxilla From 7 to 10, with at least 3 implants from canine to canine In the case of heavy stress factors, an additional anterior implant and bilateral second molar positions (to increase the anteroposterior distance) may be of benefit 39 General rule it is better to err on the side of safety in the number than on

the side of too few doub t Add an additional implant to the treatment plan 40 The minimum mesiodistal dimension for two 4 mm implant between natural teeth?? 41

1.5 mm from an adjacent natural tooth 3 mm from an adjacent implant 14 mm 7 mm 42 43 Splinted implants Seperate

units 1. Interproximal hygiene 2. Ability to replace a single unit to repair porcelain fracture 3. The margins of porcelain-to-metal crowns are most often placed under shear loads 4.

Caries risk of less than 1% within 10 years (natural teeth) 5. Less endodontic risk (natural teeth) 6. The highest prosthetic complication with single-tooth implants is abutment screw loosening 7. The site must be reimplanted, when one of the implants is failed 44

Splinted implants 1. Marginal ridges are supported by metal connectors; so the porcelain is placed under compression less porcelain fracture 2. Greater prosthesis retention 3. Transfer less force to the cement interface 4.

uncementing Implants do not decay or need endodontic therapy 5. Increase functional surface area of support 6. Increase the A-P distance (A-P spread) to resist lateral loads 7. Increase cement retention of the prosthesis

8. Decrease the risk of abutment screw loosening 9. Decrease the risk of marginal bone loss 10. Decrease the risk of implant component fracture 11. Distribute less force to the implant bodies(reduce implant body fracture 14% 1%)

12. The implant or crown site converted to a pontic using the same prosthesis when the implant is failed 45 The exception The 1. 2. body of the mandible Flexes distal to the foramen on opening Has torsion during heavy biting

a full-arch implant prosthesis replacing the first or second molars should not be splinted to molars on the opposite side 1.Cantilever 2.Two or three sections 46 Thanks for your attention Dr. Pirooz Givehchian 47

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