1

1
2553 500


CG tool


...!

case...

17

...

23

43

49

...

53

57

77

80

...
!

2552-2553

...!

-
() 28-29 2553
-
implant !

80

2553

6 ...!

...!

 case...

implant

endocrine,
CVS, CA



Plavic, Aspirin,
warfarin



implant
minor surgery
implant

implant

case...
10

(Psychosis)

dementia

multiple disorder
Ideal


implant

osteoporosis
failure rate Bisphosphonate
implant

implant
osteoporosis

case review
osteoporosis risk factor
implant

Bisphosphonate
osteonecrosis

implant

xerostomia implant

denture
tissue
complete denture
denture
design
Implant
supported overdenture

Implant retained
overdenture denture

-
denture
stability
movement extent
tissue strict
implant
check occlusion
complication


tissue

case...

11

success rate
protocol Bain and Moy
1 8
osseointegration

contraindication

healing tissue
hypocellular, hypovascular hypoxia
osteoradionecrosis

implant
implant
consensus
complete denture
implant first choice

ideal
bone, soft tissue, denture

implant

preserve bone

12

case...

implant
overdenture
space
ball
attachment

implant

case

implant
implant
prosthesis denture implant
denture denture
loss VD VD duplicate
surgical stent denture
bite block
denture

6

13

labial lingual

topical
explorer
lateral
cephalometric tangential
view

(alveoloplasty)

surgical stent

implant

case...

13

protocol

implant
retained and tissue supported
overdenture

extrusion
caries occlusion



occlusion

panoramic

skull
series PA skull

mandible focus
mandible PA mandible

Keratinized alveolar mucosa

keratinized alveolar mucosa attached gingiva

attached gingiva

periodontal probe mucosal tissue vestibule
attached gingiva
Iodine mucosa keratinized
tissue

14

case...

attached gingiva oral mucosa

periodontal probe
keratinized tissue

attached gingiva free gingival

graft implant
Lang Loe attached gingiva 2
maintain gingival health Dorfman
Tissue inflammation attachment loss
plaque bacteria
attached gingiva plaque
oral hygiene FGG

attached gingiva
implant 3
labial lingual
attached gingiva
1-1.5

attached
gingiva

incision stage II

attached gingiva
attached
gingiva labial
lingual
FGG
stage II
surgery 6

flap


soft tissue
case...

15

16

17

Clinical remounting

ecentric occlusion


clinical remount

(occlusal vertical dimension)

(plaque)



resin acrylic

resin acrylic
attachment

OVD

OVD

(clinical remount
)

centric occlusion
(slide in centric)

clinical remount

18

19

 ( )


(maximum convexity of tongue)
2/3 retromolar pad

(stability)


neutral zone


(reline)

(retention)

15 .()

PIP

20

(reline) overextension

21


resin acrylic
6
8

(flange)

PIP

(flange)

Lingual side : Acrylic thickness

acrylic resin

Mucosal Crest to Occlusal Plane

Acrylic thickness 6+ mm

22

23

...

24

25


buccolingual (
flap)

( flap)

(long shank round

bur) #6 cortex twist drill

surgical stent guide

labial lingual
1
(Leblebicioglu B, Rawal S, Mariotti A. A review of the functional
and esthetic requirements for dental implants. JADA 2007 :138;
321-329)
Vertical -
midline 20
canine first premolar

(knife edge ridge)

sharp ridge pencil
thin

sharp
ridge

mandible
mandible

sharp ridge

surgical stent guide

labial lingual
1
(Leblebicioglu B, Rawal S, Mariotti A. A review of the functional
and esthetic requirements for dental implants. JADA 2007 :138;
321-329)

26

....

alveoloplasty
1. full thickness flap knife edge
ridge periodontal probe
2. knife edge
( 6 )
3.

....

27


alveoloplasty ( ) 5
soft tissue flabby
tissue soft tissue
keratinized mucosa soft tissue
implant

6
implant
10

1.


2.

ball
attachment
transmucosal part
(

28

....

2 2.35 .
4 .)
3.




20

1.
2.
3.
1.5

( 20 )
1. pilot drill (axis)
2. final drill (axis)

medio-lateral
labio-lingual surgical stent

1. surgical stent
2. (long shank
round bur) #6
3. (pilot drill)
parallel pin

4.
5. parallel pin

....

29

 6.

fixture mount (fixture)

7.

1. pilot drill

2.
3

cover screw
fixture mount

insert

centric handpiece
drill
final drill final drill
3.4 .

30

....

fixture mount
cover screw healing
bone jumping 1
fixture mount
:
3 (
)
:
5
: 10
13
()

1. round bur

cortex
2. twrist drill

drill drill

3.

4.
(
2,000 /)
5.
irrigate


6. cortical tap
ratchet
(bone tapping)

....

31

1. 800-1,200
2. drill 2.8 final drill drill 3.4
cortex 5

(Perforation)

1.



1
2.

flap

labial lingual
periosteal
retractor



3. implant

drill

32

....

1. drill
perforation
final drill
drill

5 .
2. final drill

flap

implant
implant

-
-
-

1.

2. bone tapping

1.
2. probe

final drill

3. implant implant
13 implant 10
4. implant
tapping

drill final drill

3.4 . insert implant implant

....

33

 (dehiscence)
implant platform
platform

implant
1
flap
6 implant

2
graft
flap
dehiscence
5

fixture fixture mount (retaining screw)

retaining screw
screw driver

1 fixture
mount
retaining screw

34

....

arterial forcep

fixture
cover screw
2 Screw

implant round bur trephine bur

implant implant

1

disintegration

stage II cover screw

fixture mount ball attachment

fixture mount ball attrachment
healing abutment relief
flap
osseointegration

soft tissue

epinephrine infiltration
buccal
lingual

incision 5 10
vasoconstriction
periosteal
retractor tissue
incision
incision
bone support
....

35

 flap full
thickness
lingual
soft tissue
labial
buccal

mandible
mentalis muscle

incision muscle
bleed

5-10



arterial forcep



tissue

36

....

bone

(mental foramen)




5
loop
mandibular canal

mental foramen
bone density

spongy bone
bleeding
drill


lingual
plate
lingual flap

periosteal retractor
flap

bleeding drill
drill socket parallel pin drill
socket bleed drill

pilot drill

drill bleeding
insert
implant
bleeding
fixture mount
guide

implant

implant
fixture lock fixture
mount

1. Gemlock hex fixture

mount
fixture
2. Gemlock implant

implant fixture mount

platform
fixture mount

....

37


screw driver retaining screw fixture mount
fixture arterial forcep fixture mount
fixture mount insert
implant primary stability () fixture

implant
retaining screw
()

x-ray
cover screw

screw
driver


screw
screw driver
screw
square Ratchet
screw driver


screw

screw driver

cover
screw implant
bone
bone growth
irritate
tissue inflammation
cover screw

38

....

implant
panoramic implant

Birgit Junfin
Glass (2005)
edentulous
case 8% error
panoramic
design

89.3 %
error
position

(unseen healing cap)

surgical stage II
implant
surgical stent
stage I surgery
guide
flap

implant

mucosa
soft tissue
cover
screw
flap

cover screw
round bur

....

39

healing abutment

overgrowth mucosa healing abutment

cover screw soft

tissue bone cover screw fixture
healing abutment axis
healing abutment relief
healing abutment

healing abutment

healing abutment

flap
stage II periodontal
probe

healing abutment

1
healing abutment
flap
horizontal mattress
: healing abutment
2 3
5

healing abutment

relief

relief articulating paper

healing abutment
-
labial lingual
()
healing abutment

relief Fit checker

relief set
acrylic

40

....

1. healing
abutment
healing
abutment
flap

healing abutment
1
2.
healing abutment




chlorhexidine mouthwash
3.
5
healing
abutment
submucosal tissue

....

41

 stage II healing abutment

ball attachment pick up

stage II inflammation tissue

pick up monomer acrylic irritant tissue
tissue
healing abutment healing pick-up

Package implant
re-sterile

re-sterilization
surface fixture
contamination
osseointegration

42

....

43

Hematoma
hematoma
swelling

hematoma
swelling
operation flap
bleeding
operation

flap

tissue loose
hematoma

1
hematoma

curette
antibiotic

infection

(Numbness)

mental soft tissue part
bony part
mental retract retract flap
hematoma

44

panoramic marker
mental
foramen 7 mm.

x-ray
implant nerve implant
implant implant

injury
6
hematoma retractor

vitamin B 1-6-12

(granulation tissue)
granulation tissue
chronic infection foreign body

1. remove granulation tissue

2.
3. antibiotic

45


(Dehiscence wound)

irritation

1. cover screw

2.

3.
2
4
second stage
inflammation

flap


2

2 4

46

(Implant disintegration)

stage I
stage II
ball attachment

abutment fixture
abutment

1.


remove implant
curette socket
2.
3

implant integration

stage II

ball
attachment ball
attachment cover
screw

implant 4 x-ray
osseointegrate
healing
screw driver cover screw
osseointegration implant cover screw
12 healing implant
4 phase remodeling 8
remodeling

47

48

49

sleeve healing

abutment coping

OVD

sleeve healing
abutment coping

transmucosal base
ball

( 60 )

healing
abutment coping

15-20

transmucosal
base 4

4

> 30

transmucosal base

50

51

healing abutment

healing abutment



healing abutment

tissue
conditioner (
)
healing abutment
(5 .)
relieve

clinical chairside
reline (closed mouth technique)
burn
undercut

52

...

ball attachment
pick up Oring

53

Pick up O-ring

acrylic O-ring
acrylic acrylic
acrylic

acrylic resin

acrylic

abutment
pick up O-ring

surgical template

54

...

surgical template



surgical template

pick up O-ring

Pick up O ring

(
60 )

O- ring
pick up
transmu
cosal base
( block out
silicone

transmucosal
base
rubber dam
sheet

transmucosal
base

acrylic

pick up O-ring

Ball

implant fixture ball

screw implant fixture
ball screw
torque wrench

...

55


O - ring pick up

path of insertion

(ball burnisher, plugger)

56

...

57

 implant periodontal fiber

?
soft tissue implant () surgical stage II gingiva epithelium
connective tissue mature biological seal
implant 6-8

collagen fiber fiber

cementum, periodontal ligament, bone
collagen fiber implant implant
periosteum bone crest
connective tissue bone crest collagen fiber
fibroblast vascular structure

connective tissue attachment peri-implant mucosa

1 collagen fiber
junctional epithelium
connective tissue

2 = parallel fiber 3, 4 = cuff-like circular fiber

fiber
soft-tissue seal implant

58

biological width

59

biological width (BW)

tooth
implant
Junctional epithelium
0.971.14 mm 1.88 mm
Connective tissue attachment 0.77-1.07 mm 1.05 mm
Biological width
2.04-2.91 mm 3.08 mm

probing implant
probing depth

probe tip titanium

collgen fiber
implant

probing depth = 3 without bleeding healthy
attachment loss bone loss
reference point implant shoulder

60

implant
(stability measures)

healthy implant
73 um
low sensitivity but high
specificity (low sensitivity
for detection of bone
support, high specificity
for detection of implant
failure)

implant
stability (noninvasive)
Impact
Resistance (Periotest)
Resonance
Frequency Analysis (RFA)

implant
(horizontal bone defect)
1.5
0.1- 0.2

(vertical bone defect )
1. plague calculus
2. occlusion

61


2


2

bone wedge

Peri-implantitis ?
? ? ?
peri-implant disease
peri-implant disease (Albrektsson et al.,1994) 2
peri-implantitis peri-implant mucositis
peri-implantitis an inflammatory process
affecting the tissue around an osseointegrated implant in
function, resulting in loss of supporting bone (
periodontitis)
peri-implant mucositis a reversible inflammatory
changes of the peri-implant soft tissue without any bone loss
( gingivitis)

62

monitor implant
conditions
clinical inflammation (BOP, pus,
increased PD, redness, swelling) + progressive bone loss
peri-implant disease
67% peri-implant mucositis 91% peri-im
plantitis increased BOP (Lang et al., 1994)
BOP stable peri-implant
conditions
peri-implant probing depth
PD degree of inflammation
PD
peri-implantitis PD >5-6mm bone
loss (Ferreira et al., 2006, Berglundh et al., 2002):
radiographs
marginal bone loss implant 1-1.5
0.1- 0.2 (Adell et
al.1981) peri-implantitis x-ray
>1.8mm after 1st year (Roos-Jansaker et al.,2006)
bone loss/attachment loss >2.5 mm. (Berglundh et al.,
2002)
V bone loss (Ferreira et al., 2006)
clinical inflammation (bleeding, pus,
increased PD, redness, swelling)
plaque assessment (PI)

63

implant mobility & discomfort

osseointegration
osseo-disintegration: a late implant bone loss
implant failure, implant (Consensus Report
of the 6th European workshop of Periodontology 2008)
Peri-implant disease (Zitzmann&Berglundh et
al., 2008)
peri-implant mucositis 50% peri-implantitis
12-43%
Risk indicators (Heitz-Mayfield et al., 2008)
periodontitis
Smoking
Poor oral hygiene OR = 14.3
Peri-implant disease
Cumulative Interceptive Supportive Therapy (CIST Protocol)
(Lang et al., 2004)
PD< 3 mm

Adsence of plaque
BOP negative

No teratmet

Presence of plaque
BOP+

Mechanical
debridement +
polishing

Antiseptic
cleansing

BOP+
No bone loss

BOP+
Bone loss < 2mm

Systemic or local
antibiotic therapy

PD 4 to 5 mm

Radiograph!
PD > 5 mm

BOP+
Bone loss > 2mm

64

or
Resective
regenrative
surgery

A: Mechanical debridement
B: Antiseptic treatment
C: Antibiotic treatment
D: Regenerative or resective therapy
peri-implantitis (Kotsovilis et al., 2008 ,Lang et al.,
2004)
non-surgical treatment
closed debridement
chemical plaque control & antiseptic cleansing
: CHX mouthwash, local irrigation with CHX CHX gel
( 2 3-4 )
systemic or local antibiotic
: Metronidazole 250mgx3 alone or combined with
Amoxycillin 375mgx3
: local antibiotics with control releasing device
(Tetracycline fiber, Minocycline microsphere)
surgical treatment
access surgery & surface decontamination (
air-abrasive gauze
chlohexidine saline citric acid)
gauze soaked CHX/saline
bone graft with or without membrane to fill the
osseous defect

65

Prognosis

re-osseointegration
re-osseointegration rate peri-implantitis
1-84% (Persson et al.,2004, Schwarz et al., 2006)
type of defect, implant surface
oral hygiene
patient compliance
smoking

?
(?)
The Periodontal Risk Assessment (PRA) (Lang and Tonetti, 2003)
recall
low to moderate risk 6
moderate to high risk 3-4

Screw , ball attachment ,

tissue

ball attachment fixture

tissue growth fixture ball
fixture
screw
load Implant

66

1. fixture tissue ball attachment

2. X-ray ball attachment
3. ball attachment ( torque wrench)
4. check occlusion
5. implant
, visit
1-2

Ball ball implant ?

abutment
fixture abutment

1. abutment

2.


remove implant
curette
socket
3

67

O-ring , ,
O-ring
O-ring
6

implant 2

O-ring
O-ring
O-ring
acrylic
pick up

O-ring
acrylic lock
O-ring
pick up acylic O-ring

pick up

2. silicone soft liner space

direction
bonding load silicone soft liner
3. lower CD
upper CD

4. lower CD
blade
5. silicone soft liner 3-6
silicone soft liner retention
3-6
Existing ball attachments

Locate sites of ball attachments

Create space for silicone soft liner

Create space for silicone soft liner

O-ring

pick up O-ring
O-ring

1. space lower CD tissue surface

ball attachment 2
5 ball
attachment 1-2

68

69

Apply bonding liner

Fill in the prepared space

Put the denture back in place

Wait until material is completely set

Remove unwanted material

Use warm blade to cut off the

materials

0ring ?
O-ring 6

Oring

O-ring

Oring

overloading

Oring
acrylic resin
Oring explorer
(angle tip)
plugger Oring

acrylic resin Oring
O-ring
pick up

Apply glaze liguid

70

Wait until glaze liquid is

completely set

acrylic ( PIP )
pick up
pick up

71



PIP, fit
checker
lab
reline
ball attachment
healing
abutment O-ring

healing abutment
( ball

ball
)
adhesive
light
body silicone
set


lab

72

pick up
O-ring
(relief )
ball
attachment
seat
check occlusion

recheck

pick up O-ring
bone resorption
implant
Implant
reline
acrylic
()
seat
set

ball attachment repair

ball attachment

repair
ball attachment seat
closed mouth reline
Relining Denture : Closed mouth tech.

Closed mouth
reline technique

pick up

refracture
O-ring ball lock
acrylic ball
acrylic
acrylic set
acrylic
tissue

73

lab repair
ball attachment
seat
pick up

1
ball attachment ,
healing abutment
Resin acrylic

pick up step
denture (

)
acrylic
2 ball
attachment
alginate ball
attachment ( cast
ball )
acrylic
ball attachment
Individual
tray, bite block, ,

check denture
pick up
O-ring

74

1. implant

2.
3.
abutment cover screw

6
abutment

stage I stage II
ball

implant integration ball ball

stage II cover screw

ball cover screw

75

80
5 2550

76

77

78

1.
2.

79

80

1
1.


2.

.



( )

()

2.1
2.2
2.3

(/

)

80

81

()

3.1 ()
3.2
3.3
3.4

4
4.1




4.2
( )

0-2591-0915

82

83

110000
02951-0915
http://www.royalimplant.org

84