Implant introduction Wednesday 30th April

2013 9.00am – 4.30pm

Prior Precise Planning Prevents a Pi** Poor Performance (The 7P rule)

Is the Rx plan within my skill range?

Re-cycling – warnings – nothing lasts forever

Dentists are now twice as likely to get sued as a Doctors!

Lets look at a case we saw at St G’s in 2007

• What further special tests would aid your examination of Miss LT?

• Pulp testing of UR4 & UR1 • Mounted study models

Questions

• What options could be used to restore UR3 – including the ups and downs of each?

• Chrome Denture • Resin-Bonded Bridge(s) • Conventional Bridge • Implants

Questions

• What option would you suggest and why?

Questions

• Do you think NHS money should be used to fund her implant treatment?

Questions

• Assuming there is funding and the patient wants implants – how would you go about planning it?

• Diagnostic wax up / surgical stent / PA radiographs • Temporisation RBB 4PP1/ or RPD?

Questions

• Would you go for cemented or screw-retained crowns?

• Would you link the crowns or go for individual restorations?

Questions

• RBBs is it a good predictable option? • What RBB design would you be suggesting – cantilevers

or FF? • If implants – a RP and NP? • Screw-retained or cemented implant crowns – what

factors would you take into consideration? • Link them or single units?

Dilemmas

Fixture head impressions in an open tray

Link fixtures together or not?

How would you take a jaw registration and what would be your occlusal scheme?

12 months later

Why do you think the incisal edge of the UR3 #’d? Who’s to blame?

Miss LT 2010 – in group function with better metal support of UR3 VMK

2010

Resorbed / Pink spot lesion UL1

Angulated / customised abutments

Single tooth anterior gap in anterior maxilla – guide from evidence

• If adjacent teeth intact perfect then ideally a single tooth implant crown has a 89.4% survival at 10 years (94.5% at 5 years)

• Resin-bonded bridge has higher failure rate 65% survival at 10 years (87.7% at 5 years) but minimal biological damage

• If adjacent teeth damaged then conventional fixed dental prosthesis 89.2% survival at 10 years (93.4% at 5 years)

Single incisor gap in anterior mandible

Single incisor gap in anterior mandible

• Implant-crown and conventional FDP have similar survival outcome. • However FDP more likely to cause pulpal damage of abutments. • So single tooth implant is most ideal where bone is sufficient and

where mesio-distal space allows. • One lower incisor is a challenge for OI; although 3mm diameter

now available • If not resin bonded bridge is best option where neighbouring teeth

are good condition. • These go better when replacing lateral incisors compared to

centrals (Hussey and Linden 1996)

Multiple bound anterior incisor spaces • Similar approach – clearly a move away from FPD

and the conventional preparation of intact teeth

Double maxillary incisor space • More difficult treatment planning • UR2 UL2 8.5mm crown widths • Watch out for convergence of the roots into potential

Pontic sites • Can cantilever implants (need good length and diameter)

The game changes with missing canine(s) • OI gold standard FPD option • Conventional fixed and RBBs are much less successful

in this situation (Roberts 1970 a & b; Schwartz 1970 & Foster 1991)

LT – missing canine and lateral

Large anterior span • More than 2 pontics think RPD or OI • Evidence that 6 unit FPD can be used to replace 4

missing incisors – but what will happen on failure with young patient?

Single posterior spaces • First consider accepting the space

• RBBs de-bond at an annual rate of 5.17% posteriorly - do not go well in this part of the mouth

• If patient wants restoration we need to consider health of adjacent teeth

• Ideally a single tooth implant

• Conventional FDP only if adjacent teeth require crowns (damaged abutments)

• Conventional FDPs will do poorly if abutments are previously RCT’d (Palmqvist 1991) or go on to require RCT after cementation (Reuter and Brose 1984)

RBBs struggle to restore molar teeth – avoid losers as you will damage natural teeth

unnecessarily

Multiple missing adjacent teeth in the posterior region

• Consider accepting space and SDA

• Gold restorative standard an implant-supported FDP as shorter extension than conventional bridgework (no retainers) - greater risk of technical complications (e.g. porcelain chipping) due to functional position and lack of periodontal ligament bounce

• Conventional FPD only where abutments are damaged and require cuspal protection

• Forget RBBS

• Bounded RPDs can work very well with good oral health

Restoring free end saddles and the shortened arch

• Consider implant-supported crowns and FPDs as RPD will not improve patient’s QoL

• OI surgery gets more difficult the further you go back in the mouth due to anatomical features

• Consider Cantilever conventional FPD / RBBs to increase number of occlusal units

• Other options include distal tooth-supported cantilever and tooth-implant supported FDP but these have higher failure rates.

Summary Hopefully we have covered:

• Clinical implant stages • What clinical things need to be in place • Which restoration types are / are not most appropriate

to fill prosthodontic spaces? • How well are our different types of restoration likely to

perform in given clinical situations? • Where is an implant better than others

I hope this has been interesting and educational

The End