Practical Procedures in Implant Dentistry

Practical Procedures in Implant Dentistry
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Master the fundamentals and intricacies of implant dentistry with this comprehensive and practical new resource Practical Procedures in Implant Dentistry delivers a comprehensive collection of information demonstrating the science and clinical techniques in implant dentistry. Written in a practical and accessible style that outlines the principles and procedures of each technique, the book offers clinical tips and references to build a comprehensive foundation of knowledge in implantology. Written by an international team of contributors with extensive clinical and academic expertise, Practical Procedures in Implant Dentistry covers core topics such as: Rationale and assessment for implant placement and restoration, including the diagnostic records and surgical considerations required for optimal planning and risk management Incision design considerations and flap management, with an essential knowledge of regional neuro-vascular structures Implant placement, encompassing the timing of the placement, bone requirements and understanding the importance of the peri-implant interface for soft tissue stability Impression techniques, loading protocols, digital workflows and the aesthetic considerations of implants Prosthetic rehabilitation of single tooth implants to fully edentulous workflows, including discussions of soft tissue support, biomechanics and occlusal verification Perfect for both general dental practitioners and specialists in implant dentistry, Practical Procedures in Implant Dentistry is also a valuable reference to senior undergraduate and postgraduate dental students.

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Группа авторов. Practical Procedures in Implant Dentistry

Table of Contents

List of Tables

List of Illustrations

Guide

Pages

Practical Procedures in Implant Dentistry

Foreword

List of Contributors

About the Companion Website

1 Introduction

References

2 Patient Assessment and History Taking

2.1 Principles

2.1.1 Medical History

2.1.2 Medications and Allergies

2.1.3 Past Medical History

2.1.3.1 Cardiovascular Disorders

2.1.3.2 Diabetes Mellitus

2.1.4 Age

2.1.5 Smoking

2.1.6 Osteoporosis and Bisphosphonate Therapy

2.1.7 Radiotherapy

2.1.8 Dental History

2.1.9 Social History

2.2 Tips

References

3 Diagnostic Records

3.1 Principles. 3.1.1 Diagnostic Imaging and Templates

3.1.1.1 Three‐Dimensional Imaging

3.1.1.2 Templates

3.1.2 Guided Surgery

3.1.3 Diagnostic Records. 3.1.3.1 Articulated Study Models

3.1.3.2 Photographic Records

3.2 Procedures. 3.2.1 Template Design. 3.2.1.1 Traditional Templates

3.2.1.2 Digital Templates

3.2.2 Photography

3.3 Tips

References

4 Medico‐Legal Considerations and Risk Management

4.1 Principles

4.1.1 Informed Consent

4.2 Procedures. 4.2.1 Dental Records

4.3 Tips

Reference

5 Considerations for Implant Placement: Effects of Tooth Loss

5.1 Principles

5.1.1 Local Site Effects of Tooth Loss

5.1.2 Effects of Tooth Loss on the Individual Level

5.1.3 Effects of Tooth Loss on the Population Level

5.2 Procedures

5.3 Tips

References

6 Anatomic and Biological Principles for Implant Placement

6.1 Principles

6.1.1 Osteology

6.1.2 Innervation and Vascular Supply

6.1.3 Musculature

6.2 Procedures

6.3 Tips

References

7 Maxillary Anatomical Structures

7.1 Principles

7.2 Maxillary Incisive Foramen and Canal

7.2.1 Importance in Oral Implantology

7.3 Nasal Cavity

7.3.1 Importance in Oral Implantology

7.4 Infraorbital Foramen

7.4.1 Importance in Oral Implantology

7.5 Maxillary Sinus

7.5.1 Importance in Oral Implantology

7.6 Greater Palatine Artery and Nerve

7.6.1 Importance in Oral Implantology

References

8 Mandibular Anatomical Structures

8.1 Principles

8.2 Mental Foramen and Nerve

8.2.1 Importance in Oral Implantology

8.3 Mandibular Incisive Canal and Nerve

8.3.1 Importance in Oral Implantology

8.4 Genial Tubercles

8.4.1 Importance in Oral Implantology

8.5 Lingual Foramen and Accessory Lingual Foramina

8.5.1 Importance in Oral Implantology

8.6 Sublingual Fossa

8.6.1 Importance in Oral Implantology

8.7 Submental and Sublingual Arteries

8.7.1 Importance in Oral Implantology

8.8 Inferior Alveolar Canal and Nerve

8.8.1 Importance in Oral Implantology

8.9 Lingual and Mylohyoid Nerves

8.9.1 Importance in Oral Implantology

8.10 Submandibular Fossa

8.10.1 Importance in Oral Implantology

8.11 Mandibular Ramus

8.11.1 Importance in Oral Implantology

References

9 Extraction Ridge Management

9.1 Principles

9.2 Osteoconductive Materials for Ridge Management

9.3 Biologically Active Materials for Ridge Management

9.4 Influence of Buccal Wall Thickness on Ridge Management

References

10 Implant Materials, Designs, and Surfaces

10.1 Principles

10.2 Implant Bulk Materials

10.2.1 Pure Titanium Used for Implant Bulk Material

10.2.2 Titanium Alloys Used for Implant Bulk Material

10.2.3 Zirconia Used for Implant Bulk Material

10.2.4 Other Materials as Bulk Implant Material

10.3 Implant Surface Treatments

10.4 Implant Design

10.4.1 Implant Body Shape Design

10.4.2 Implant Thread Design

10.4.3 Implant Connection Designs

10.4.4 Which Implant Connections Are Better and Why?

10.5 Summary

References

11 Timing of Implant Placement

11.1 Principles

11.1.1 Classification for Timing of Implant Placement

11.1.2 Immediate Placement

11.1.3 Delayed Implant Placement. 11.1.3.1 Resolution of Local Infection

11.1.3.2 Dimensional Changes of the Alveolar Ridge

11.2 Procedures

11.2.1 Systemic Risk Factors

11.2.2 Local Risk Factors

11.2.3 Biomaterials

11.2.4 Socket Morphology

11.2.5 Flapless Protocol

11.2.6 Clinician Experience

11.2.7 Adjunctive Procedures with Implant Placement. 11.2.7.1 Simultaneous Bone Augmentation with Implant Placement

11.2.7.2 Adjunctive Soft Tissue Grafting

11.2.8 Selecting the Appropriate Treatment Protocol

11.3 Tips

References

12 Implant Site Preparation

12.1 Principles

12.2 Assessing Implant Sites and Adjacent Teeth

12.2.1 Periodontal Charting

12.2.2 Assessment of Gingival Biotype and Attached Mucosa

12.2.3 Photography

12.2.4 Aesthetic Assessment

12.2.5 Radiography

12.2.6 Occlusal Analysis

12.2.7 Endodontic Status of Adjacent Teeth

12.3 Site Preparation

12.3.1 Grafting – Sinus, Buccal, Soft Tissue

12.3.2 Occlusion

12.3.3 Adjacent and Opposing Teeth

12.3.4 Crown Lengthening and Gingivectomy

12.3.5 Orthodontics and Site Preparation

12.3.6 Provisional Phase

References

Further Reading

13 Loading Protocols in Implantology

13.1 Principles

13.1.1 Definitions

13.1.2 Conventional Loading

13.1.3 Early Loading

13.1.4 Progressive Loading

13.1.5 Immediate Loading

13.2 Procedures. 13.2.1 Selecting a Loading Protocol

13.2.2 Methods of Evaluation of the Primary Stability for Immediate Loading

13.3 Tips

References

14 Surgical Instrumentation

14.1 Principles

14.1.1 Mirror, Probe, and Tweezers

14.1.2 Scalpel Handles

14.1.3 Scalpel Blades

14.1.4 Curettes

14.1.5 Needle Holders

14.1.6 Periosteal Elevators

14.1.7 Retractors

14.1.8 Depth Probe

14.1.9 Tissue Forceps/Pliers

14.1.10 Mouth Props/Bite Blocks

14.1.11 Scissors

14.1.12 Extraction Forceps, Periotomes and Elevators

14.1.13 Kidney Dish

14.1.14 Surgical Kit, Electric Motor, 20:1 Handpiece, and Consumables

14.1.15 Grafting Well

14.2 Optional Instrumentation. 14.2.1 Rongeurs

14.2.2 Benex

14.2.3 Bone Harvesters

14.2.4 Anthogyr Torq Control

14.2.5 Piezosurgery

14.3 Tips

15 Flap Design and Management for Implant Placement

15.1 Principles. 15.1.1 Neurovascular Supply to Implant Site

15.1.2 Flap Design and Management

15.1.3 Types of Flap Reflection

15.2 Procedures. 15.2.1 Tissue Punch

15.2.2 Envelope Flap

15.2.3 Triangular (Two‐Sided) and Trapezoidal (Three‐Sided) Flap

15.2.4 Papilla‐Sparing Flap

15.2.5 Buccal Roll

15.2.6 Palacci Flap

15.3 Tips

References

16 Suturing Techniques

16.1 Principles

16.1.1 Types of Sutures

16.1.1.1 Absorbable Sutures

16.1.1.2 Non‐absorbable Sutures

16.1.2 Suture Adjuncts

16.1.3 Suture Size

16.1.4 Needle

16.2 Procedures. 16.2.1 Simple/Interrupted Sutures

16.2.2 Continuous/Uninterrupted Suture

16.2.3 Mattress Sutures

16.2.3.1 Horizontal Mattress

16.2.3.2 Vertical Mattress

16.2.4 Suture Removal

16.3 Tips

17 Pre‐surgical Tissue Evaluation and Considerations in Aesthetic Implant Dentistry

17.1 Principles

17.2 The Influence of Tissue Volume on Peri‐implant ‘Pink’ Aesthetics

17.3 Tissue Volume Availability and Requirements

17.3.1 Hard Tissue Requirements (Figure 17.3 and 17.4)

17.3.2 Soft Tissue Requirements (Figure 17.5)

17.4 Pre‐operative Implant Site Assessment (Figures 17.6 and 17.7)

17.5 Key Factors in Diagnosis of the Surrounding Tooth Support Prior to Extraction

17.5.1 Integrity of the Interproximal Height of Bone

17.5.2 Essential Criteria Evaluation Prior to Extraction

17.5.3 Integrity of the Buccal Plate of Bone

17.6 Tips

17.7 Conclusion

References

18 Surgical Protocols for Implant Placement

18.1 Principles

18.1.1 Implant Positioning

18.2 Procedures

18.2.1 One‐Stage versus Two‐Stage Protocols

18.2.2 Post‐operative Management Protocols

18.3 Tips

References

19 Optimising the Peri‐implant Emergence Profile

19.1 Principles

19.1.1 The Peri‐implant Emergence Profile

19.2 Procedures. 19.2.1 Single‐Stage versus Two‐Stage Implant Surgery

19.2.2 Buccal Roll Flap

Steps

19.2.3 Pouch Roll Technique [4]

Steps

19.2.4 Apically Repositioned Flap

Steps

19.2.5 Buccally Repositioned Flap

Steps

19.2.6 Free Gingival Graft

Steps – Recipient Site Preparation

Steps – Harvesting of the Free Gingival Graft

Steps – Preparation and Stabilisation of the Free Gingival Graft

19.3 Tips

References

20 Soft Tissue Augmentation

20.1 Principles

20.1.1 Types of Oral Soft Tissue

20.1.2 Anatomical Considerations for Harvesting Autogenous Soft Tissue Grafts. 20.1.2.1 Hard Palate

20.1.2.2 Tuberosity

20.1.2.3 Buccal Attached Gingiva of Maxillary Molars

20.1.3 Soft Tissue Substitutes. 20.1.3.1 Allogenic Origin

20.1.3.2 Xenograft Origin

20.1.4 Purpose of Soft Tissue Graft (Periodontal Plastic Surgery) 20.1.4.1 Aesthetic Purpose

20.1.4.2 Functional Purpose

20.2 Procedures. 20.2.1 Techniques. 20.2.1.1 Harvesting the Palatal Tissue Graft as a Free Gingival Graft and Connective Tissue Graft

20.2.1.2 Root Coverage

20.2.1.3 Soft Tissue Augmentation Prior to Bone Grafting

20.2.1.4 Soft Tissue Graft to Gain Keratinised Tissue

20.3 Tips

References

Further Reading

21 Bone Augmentation Procedures

21.1 Principles

21.1.1 Why is Bone Grafting Necessary?

21.1.2 Defect Topography Classification

21.1.3 Requirements for Successful Tissue Grafting

21.1.4 Materials Used for Augmentation. 21.1.4.1 Autogenous Bone

21.1.4.2 Membranes

21.1.4.3 Membrane Fixation Systems

21.2 Procedures. 21.2.1 Bone Graft with Non‐resorbable Membrane (Figures 21.2 and 21.3)

21.2.2 Autogenous Bone Graft (Figures 21.4–21.10)

21.3 Tips

References

22 Impression Taking in Implant Dentistry

22.1 Principles

22.1.1 Impression Techniques Used in Implant Dentistry

22.1.1.1 Abutment Level Impressions

22.1.1.2 Implant Level Impressions

22.1.2 Customised Impression Copings

22.1.3 Multiple Unit Impressions

22.2 Procedures

22.2.1 Implant Level Impression

22.2.2 Digital Impressions

22.3 Tips

References

23 Implant Treatment in the Aesthetic Zone

23.1 Principles

23.1.1 General Considerations

23.1.1.1 Lip Contour and Length

23.1.1.2 Tooth Display at Repose and in Broad Smile

23.1.1.3 Smile Line

23.1.1.4 Teeth Length, Shape, Alignment, Contour, and Colour

23.1.1.5 Gingival Display, Gingival Zeniths, and Papillae of Maxillary Anterior Teeth

23.1.1.6 Width of Edentulous Space

23.1.1.7 Gingival Biotype

23.1.2 Major Deficiencies in Hard and Soft Tissues

23.2 Procedures

23.2.1 Assessment of Gingival Biotype

23.2.2 Clinical Management

23.2.3 Timing of Implant Placement

23.2.4 Thickness of Soft Tissues

23.3 Tips

References

24 The Use of Provisionalisation in Implantology

24.1 Principles

24.1.1 Prosthetically Guided Tissue Healing

24.2 Procedures

24.2.1 Direct Techniques

24.2.2 Indirect Techniques

24.3 Tips

Reference

25 Abutment Selection

25.1 Principles

25.1.1 Custom Abutments

25.1.2 Prefabricated (Stock) Abutments

25.1.3 Material Selection

25.1.4 Abutment Design

25.2 Procedures

25.3 Tips

References

26 Screw versus Cemented Implant‐Supported Restorations

26.1 Principles

26.1.1 Retrievability

26.1.2 Aesthetics

26.1.3 Passivity

26.1.4 Hygiene (Emergence Profile)

26.1.5 Reduced Occlusal Material Fracture

26.1.6 Inter‐arch Space

26.1.7 Occlusion

26.1.8 Health of Peri‐Implant Tissue

26.1.9 Provisionalisation

26.1.10 Clinical Performance

26.2 Procedures

26.2.1 Screw‐Retained Restoration

26.2.2 Cement‐Retained Restoration

26.2.3 Lateral Set‐Screw (Cross‐Pinning)

26.2.4 Angle Screw Correction/Bi‐axial Screws

26.3 Tips

References

27 A Laboratory Perspective on Implant Dentistry

27.1 The Shift from Analogue to Digital

27.2 Standards in Manufacturing Today

27.3 The Importance of Implant Planning for the Laboratory

27.4 Digital Planning to Manage Aesthetic Cases

27.5 Scanning for Implant Restorations

27.6 Digital Data Acquisition for Full Arch Cases

27.7 Inserting Full Arch Cases at Surgery

27.8 Tips

28 Implant Biomechanics

28.1 Principles

28.1.1 Forces and their Nature

28.1.1.1 Pressure = Force/Area

28.1.1.2 Impulse = Force/Time

28.1.1.3 Compressive, Tensile, and Shear Forces

28.1.1.4 Application to Materials and Occlusion

28.1.1.5 Incline Plane Mechanics (Normal Force)

28.1.2 Beams

28.1.3 Levers

28.1.4 Cantilevers

28.1.5 Bone

Reference

Further Reading

29 Delivering the Definitive Prosthesis

29.1 Principles

29.1.1 Soft Tissue Support

29.1.2 Occlusal Verification

29.1.3 Aesthetic Evaluation

29.1.4 Torque Requirement for Delivery

29.1.5 Cementation Technique and Material Selection – Cemented Crowns

29.1.6 Screw Access Channel Management – Screw‐Retained Crowns

29.1.7 Pink Porcelain

29.2 Procedures

29.2.1 Delivering a Cement‐Retained Crown – Chairside Copy Abutment Technique

29.2.1.1 Creating a Polyvinyl Siloxane Copy Abutment

29.2.1.2 Delivering a Cement‐Retained Crown Using a Copy Abutment Technique

29.3 Tips

References

30 Occlusion and Implants

30.1 Principles

30.1.1 Excessive Forces on Dental Implants

30.1.2 Bruxism and Implants

30.2 Procedures

30.2.1 Clinical Occlusal Applications

30.3 Tips

References

31 Dental Implant Screw Mechanics

31.1 Principles

31.1.1 Factors Affecting Implant Screw Joint Stability. 31.1.1.1 Preload

31.1.1.2 Embedment Relaxation (Settling Effect)

31.1.1.3 Screw Material and Coating

31.1.1.4 Screw Design

31.1.1.5 Abutment/Implant Interface Misfit

31.1.1.6 Abutment/Implant Interface Design

31.1.1.7 Functional Forces

31.1.1.8 Number of Implants

31.1.1.9 Torque Wrench

31.2 Procedures

31.2.1 Techniques for Retrieving a Fractured Screw. 31.2.1.1 The Ultrasonic Scaler Technique [11]

31.2.1.2 Screwdriver Technique

31.2.1.3 Manufacturer Rescue Kits

31.3 Tips

References

32 Prosthodontic Rehabilitation for the Fully Edentulous Patient

32.1 Principles

32.1.1 Number of Implants for Full Arch Implant Rehabilitation. 32.1.1.1 Removable Overdenture

32.1.2 Fixed Implant‐Supported Bridgework

32.2 Procedures. 32.2.1 Occlusal Vertical Dimension

32.2.2 Phonetics

32.2.3 Swallowing

32.2.4 Facial Appearance

32.2.5 Impression Taking

32.2.6 Abutment Selection

32.2.7 Prosthodontic Options for Fixed Bridgework

32.2.8 Occlusion

32.3 Tips

References

33 Implant Maintenance

33.1 Principles

33.1.1 Radiographic Analysis

33.2 Procedures

33.3 Tips

References

34 The Digital Workflow in Implant Dentistry

34.1 Components and Steps of the Digital Implant Workflow. 34.1.1 Digital Diagnostic Impression

34.1.2 Cone Beam Computed Tomography

34.1.3 Digital Implant Treatment Planning

34.1.4 The Digital Surgical Guide

34.1.5 Pre‐surgical Fabricated Temporary Prosthesis

34.1.6 Guided Implant Surgery

34.1.7 Implant Digital Impressions

34.1.8 Manufacturing of the Customised Prosthesis

References

35 Biological Complications

35.1 Principles

35.1.1 Attachment Differences

35.1.2 Crestal Bone Loss

35.1.3 Peri‐implant Disease

35.1.3.1 Prevalence of Peri‐implant Diseases

35.1.3.2 Risk Factors in Peri‐implant Disease

35.1.3.2.1 Cement versus Screw Retention

35.1.3.2.2 Prosthodontic Contour

35.1.3.2.3 Prosthodontic Design (Accessibility for Hygiene)

35.1.3.2.4 Implant Surface

35.2 Procedures. 35.2.1 Treatment of Peri‐implant Disease

35.2.1.1 Methods of Decontamination

35.2.1.1.1 Mechanical Decontamination

35.2.1.1.2 Chemical Decontamination

35.2.1.1.3 Lasers and Photodynamic Therapy

35.2.2 Treatment of Peri‐implant Mucositis

35.2.3 Treatment of Peri‐implantitis

35.2.3.1 Non‐surgical Therapy for Peri‐implantitis

35.2.3.2 Surgical Therapy for Peri‐implantitis

35.2.4 Recommendations

35.2.5 Supportive Care

35.3 Tips

References

36 Implant Prosthetic Complications

36.1 Principles

36.1.1 Incidence of Prosthetic Complications. 36.1.1.1 Implant‐Supported Single Tooth Crowns and Implant‐Fixed Dental Prostheses

36.1.1.2 Full Arch Implant‐Fixed Dental Prostheses

36.1.2 Aetiology of Prosthetic Complications

36.1.2.1 Mechanical Overloading

36.1.2.2 Cement Excess

36.1.2.3 Proximal Contact Loss

36.2 Procedures. 36.2.1 Occlusion

36.2.2 Unfavourable Implant Position

36.2.3 Anterior Implants

36.2.4 Implant Fracture

36.2.5 Screw Loosening

36.2.6 Abutment Screw Fracture

36.2.7 Stripped Screw Head

36.2.8 Passive Fit

36.2.9 Mechanical and Biological Complications of Framework Misfit

36.2.10 Impression Technique

36.2.11 Gingival Fistula

36.2.12 Prevention of Prosthetic Complications

36.3 Tips

References

Index

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Edited by

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Further technological advances have led to the launch of dynamic surgical navigation (e.g. X‐Guide™; X‐Nav Technologies) in which real‐time surgery is guided using computer software and delivers interactive information to improve the precision and accuracy of implant positioning.

Study models that have been articulated with a facebow transfer record and a maxillo‐mandibular relationship (MMR) record allow the clinician to measure and analyse occlusal relationships and spatial considerations, and to manufacture templates. The casts can be used to create a diagnostic set‐up of the proposed prosthesis using wax and/or denture teeth. This set‐up may then be transferred to the mouth to be evaluated, used as a radiographic guide or a surgical guide, and potentially transformed into a provisional restoration. More recently, the use of chairside intra‐oral scanning, DICOM data files from CBCT, and STL files from 3D optical scanning are merged to allow planning with interactive 3D software. The proposed virtual set‐up of teeth allows visualisation of the planned restoration in relation to the bone and soft tissue architecture. This allows analysis of the bony ridge in relation to the planned tooth position, so that the length, diameter, position, and alignment of implants can be determined accurately.

.....

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