Dr. med. dent Julia- Gabriela Wittneben MMSc

Transcription

1 Dr. med. dent Julia- Gabriela Wittneben MMSc Prosthodontist Senior Lecturer Department of Reconstructive Dentistry University of Bern Part-time Faculty Member I Lecturer I Harvard University I USA Visiting Assistant Professor I TUFTS University I USA In the anterior region a CAD/CAM individualized abutment made of zirconium dioxide is beneficial for the final esthetic outcome. In the clinic I have been using CARES CAD/CAM fabricated zirconium dioxide abutments since 2009 on a routine base in esthetic cases with bone level implants and I am very satisfied with the overall outcome.

2 Indication - single crowns cemented or screw retained - FDP with cement retained bridge - esthetic zone (not recommended in the posterior region)

3 Advantages - CAD/CAM offers steady quality outcomes - Individualization possible also in respect to the emergence profile and the angulation - Esthetic advantages- overall with allceramic restorations and in respect to the soft tissue especially with thin soft tissue biotypes - Biocompatibility and excellent soft tissue integration

4 Clinical Guidelines using Zirconia Abutments - CAD/CAM design. If the reconstruction will be screw retained- the abutment represents the framework of the crown - therefore it has to be designed to create a proper support for the weak veneering ceramic, otherwise chipping or fracture of the ceramic crown might be the consequence.

5 Clinical Guidelines using Zirconia Abutments - Handling. If It is important to check on the abutment prior to insertion: was the abutment grinded from the dental technician at any time? is this the right screw? was the connection which goes into the implant adjusted by the technician? does the walls of the abutment provide enough support?

6 Clinical Guidelines using Zirconia Abutments - Handling during insertion. During insertion of the abutment you should first find the right position without any screw involved and if you feel that it is in a clear and stable position only then tighten the screw. Take a radiograph after insertion to evaluate the position - Respect the indication. For anterior and premolar prostheses, zirconia abutments may be indicated. However, they should not be ground, abraded or adjusted by the clinician or technician following sintering, unless recommended by the manufacturer.

7 Clinical Guidelines using Zirconia Abutments - Screw versus cement retention. Choosing the right retention type depends on the prosthetic position of the implants. = > please see the clinical recommendation according to the ITI Consensus Conference 2013 and publication by Wittneben et al. Wittneben JG, Millen C, Brägger U. Clinical performance of screw versus cement-retained fixed implantsupported reconstructions a systematic review. Int J Oral Maxillofac Implants. 2014;29 Suppl: Wismeijer D, Brägger U, Evans C, Kapos T, Kelly JR, Millen C, Wittneben JG, Zembic A, Taylor TD. Consensus Statements and Recommended Clinical Procedures Regarding Restorative Materials and Techniques for Implant Dentistry. Int J Oral Maxillofac Implants. 2014;29(Supplement):

8 CLINICAL RECOMMENDATIONS ACCORDING TO THE ITI CONSENSUS CONFERENCE 2013 Cement retention may be recommended: for short span prostheses with margins at or above tissue level to simplify fabrication procedures to enhance esthetics when the screw access passes trans-occlusally or in cases of malposition of the implant when an intact occlusal surface is desirable to reduce initial treatment costs It is recommended that the clinician understands that the procedures involved with cement retention for implant-supported crowns are not simple and should be carried out with great caution. - Wittneben JG, Millen C, Brägger U. Clinical performance of screw versus cement-retained fixed implant-supported reconstructions a systematic review. Int J Oral Maxillofac Implants. 2014;29 Suppl: Wismeijer D, Brägger U, Evans C, Kapos T, Kelly JR, Millen C, Wittneben JG, Zembic A, Taylor TD. Consensus Statements and Recommended Clinical Procedures Regarding Restorative Materials and Techniques for Implant Dentistry. Int J Oral Maxillofac Implants. 2014;29(Supplement):

9 CLINICAL RECOMMENDATIONS ACCORDING TO THE ITI CONSENSUS CONFERENCE 2013 Screw retention may be recommended: In situations of minimal interarch space to avoid a cement margin and thus the possibility of cement residue. This may be particularly important if the prosthetic margin is placed submucosally. Margins placed >1.5 mm submucosally have been shown to be more difficult to completely remove cement residue. when retrievability is of importance in the esthetic zone to facilitate tissue contouring and conditioning in the transition zone (emergence profile) - Wittneben JG, Millen C, Brägger U. Clinical performance of screw versus cement-retained fixed implant-supported reconstructions a systematic review. Int J Oral Maxillofac Implants. 2014;29 Suppl: Wismeijer D, Brägger U, Evans C, Kapos T, Kelly JR, Millen C, Wittneben JG, Zembic A, Taylor TD. Consensus Statements and Recommended Clinical Procedures Regarding Restorative Materials and Techniques for Implant Dentistry. Int J Oral Maxillofac Implants. 2014;29(Supplement):

10 Extended edentulous space in the anterior zone Case H Patient was edentulous since 13 years, wearing a removable partial denture.three bone level type implants were inserted and via wax up the future restoration outline was evaluated frontal and profile views.

11 CAD/CAM design Wax- up was scanned and framework made of zirconium dioxide designed so that there is a proper support for the veneering ceramic of the future bridge. Try- in of abutments and framework and verification of the bite situation.

12 Insertion of the final bridge with the use of a temporary cement.

13 Final restoration

14 Surgeon: Prof. Dr. D. Buser Prosthodontist: Dr. Wittneben Dental Technician: T. Furter CDT, Art Dent Bern

15 If you are interested in more details about the topic extended edentulous space in the esthetic zone - = > see ITI Treatment Guide 6

16 Single edentulous space in the anterior zone Case S Patient had bike accident when she was a child. Successful root canal treatment for many years. However now clinical sign of pus exudate tooth nr 11. Radiograph shows external and internal root resorption. Cone Beam CT shows thin buccal plate. Patient has high gummy smile and triangular shape teeth with a thin tissue biotype.

17 Risk Assessment Risk Factors Straightforward Advanced Complex Patient`s expectation low medium high Smile Line low medium high Gingival biotype Low-scalloped, thick Medium-scalloped, medium thick High-scalloped, thin Soft tissue contour Intact defect Proportions of neighbouring teeth Shape/Length of tooth crowns Bone anatomy of alveolar crest symmetric asymmetric asymmetric average esthetic result high esthetic result high esthetic result no bone deficiency horizontal bone deficiency vertical bone deficiency Shape of tooth crowns Rectangular Triangular modified from: Esthetic Risk Assessment, ITI Treatment Guide Vol 1, SAC Classification of Implant Dentistry

18 Single edentulous space in the anterior zone Case S Tooth was extracted without a flap. Bone level implant was placed using the early implant placement concept and GBR procedures. Implant was loaded with a screw retained provisional using the early implant loading concept after 6 weeks.

19 Single edentulous space in the anterior zone Case S Mucosal profile before soft tissue conditioning with a screw-retained implant supported provisional restoration.

20 Peri-implant soft tissue conditioning with provisonal restorations in the esthetic zone the dynamic compression technique. Wittneben JG, Buser D, Belser U, Brägger U. Int J Periodontics Restorative Dent Jul-Aug;33(4): Step - by - Step: 1. add selective pressure 2. create space for soft tissue to mature 3. recall

21 5 months post insertion of provisional Soft tissue conditioning using the dynamic compression technique. Transfer with an individualized impression coping to the master model.

22 CAD/CAM design

23 1-year follow-up

24 5-year follow-up Surgeon: Prof. Dr. D. Buser Prosthodontist: Dr. Wittneben Dental Technician: T. Furter CDT, Art Dent Bern

25 If you are interested in more details about abutment selection => see my module at the ITI Online Academy!