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28 Dental Tribune Middle East & Africa Edition | November-December 2014implant tribune < Page 27 SameDay Dental Implants® Brånemark Osseointegration Center Dubai Building 39, Dubai Health Care City tel: +971(0)44275010 email: info@samedayme.com web: www.samedayme.com Dr.CostaNicolopoulosBDS cumlaude,FFD(SA)MFOS Dr.PetrosYuvanogluDMDsumma cumlaude,Cert.Prosth(TUFTS,USA) Contact Information dontic treatment planning is im- perative. From the prosthodontic point of view, each patient’s smile, mouth and occlusion are evalu- ated with the help of photos and videos (dynamic picture). Im- pressions are taken and the di- agnostic models are mounted. If needed, the digital smile design (DSD) (Fig. 17) concept is used in order to proceed with a diag- nostic wax-up. From the waxed models, “silicone keys” of the buccal/lingual surfaces of the teeth, are fabricated, which will be used during the surgery to guide the implant placement. Impression During Surgery An impression of the implants is taken during the surgery, either at implant level for single im- plants or at abutment level for multiple implant cases. It’s imperative to make sure that the impression copings are seat- ed all the way onto the implants (periapical x-rays can be used for verification). For the impression, the open tray technique is recommended with the use of very hard addi- tion cured silicon impression material. At the end of each surgery, pre- operative impressions, impres- sion of the implants and bite registration are provided to the dental lab (Fig. 18). The dental technician mounts the implant models and starts the fabrication of the implant prosthesis. Single Implant Reconstruction For single implant cases the permanent, screw retained, all ceramic zirconia teeth are fabri- cated immediately with the use of prefabricated zirconia cores (Fig. 19). They are available in different sizes and shapes, ac- cording to the prosthetic plat- form of the implant in use and the available prosthetic space, between the adjacent teeth. While the patient is waiting in the recovery room the dental technician grinds and shapes the zirconia core and eventually bakes the porcelain on to it. Four to six hours later the per- manent tooth is placed into the mouth of the patient and the prosthetic screw is torqued down to 45Ncm. A periapical x-ray helps to verify the perfect fit (5μ) on to the implant (Fig. 20). Occlusion is checked and verified with the help of 8μ thick “schimstock” articulating paper. The prosthetic access hole is ob- turated with a two layered filling (teflon tape + opaque composite resin) to allow easy access for retrievability in the future but simultaneously excellent esthet- ics. Two months later upon matura- tion of the soft tissues and osse- ointegration, an additional x-ray is taken and if needed modifica- tions are made to the prostheses. Multiple Implants Reconstruc- tion 1)Temporary Teeth For multiple implant cases (three unit bridges to full mouth reconstructions), the temporary screw retained acrylic teeth are fabricated by the in house dental lab within five to six hours and are delivered immediately to the patient on the same day. Providing the temporary teeth immediately, isn’t only a great service to the patient but is also the best “diagnostic tool” for the restorative dentist to record all necessary information for the fabrication of the permanent teeth. If needed modifications are easily made to the acrylic teeth either directly in the mouth or in the dental lab. The patient should be evalu- ated for esthetics, phonetics and occlusion. Midline, plane of oc- clusion and buccal corridors are established. The “S” and “F” sounds are checked. The oc- clusal scheme is adjusted. For extensive cases the “mutually protected occlusion” (Fig. 21) is established which means that in centric occlusion, all teeth are touching but the posterior teeth have slightly heavier contacts compared to the anterior and on lateral and protrusive excursive movements the anterior teeth are touching/guiding and there are no posterior “working” or “non-working” interferences (anterior guidance). X-rays are taken in order to verify the pas- sive fit of the prosthesis. Once all necessary modifica- tions are made and the patient is satisfied, we need to convey all newly established parameters to the dental technician. This is achieved by: i) taking photos and videos to record the esthetic result, in the mouth and ii) using the so-called “Clinical Remounting Procedure”, in the laboratory. Alginate impressions and bite registration are taken from the temporary teeth, which are re- moved from the mouth and re- mounted again on the articula- tor. From the newly remounted temporary teeth the dental tech- nician fabricates: i) a series of silicon keys which will guide him to fabricate the permanent teeth and ii) an “An- terior Custom Made Guiding Table” (fig 22) which will allow him to reproduce the occlusal scheme of the temporary teeth to the permanent teeth. Twenty minutes later the tem- porary teeth are placed again in the mouth of the patient and the prosthetic screws are torqued to 20 Ncm. He is instructed not to bite hard onto the acrylic teeth and oral hygiene instructions are provided to him. 2) Permanent Teeth Fabrication The dental lab, with the help of i) the interchangeable implant and temporary models, ii) the silicon keys, iii) the anterior cus- tom made guiding table, iv) the photos and v) the videos starts to fabricate immediately the per- manent screw retained porce- lain teeth. The permanent teeth need to be ready in one-week’s time and should have perfect fit onto the implants. This is one of the most important prerequisites for opti- mal implant longevity. The material of choice, used by our dental lab, for the past 20 years, is porcelain fused to met- al. The fabrication of the metal ceramic prosthesis involves a series of technique sensitive procedures. Inevitably in each step, small “3 dimensional inac- curacies” are introduced into the prosthesis. The sum of these in- accuracies is never zero. As a re- sult, at the end of the fabrication procedure, the final prosthesis will never have a perfect fit onto the implants. The use of the “Passive Abut- ment” (Fig. 23), which is a tita- Fig. 16. Implants should not be loaded during the “Stability Dip” period. Fig. 17. Before/After Digitally Designed Smile Fig. 19. Prefabricated Zirconia Cores in different shapes and sizes. Fig. 22. The Anterior Custom Made Guiding Table. Fig.27. SameDay Dental Im- plants® & Teeth with Angled and Wide implants. Fig. 24. The “One Piece Screw Retained” Prosthesis. Fig. 20. Periapical x-ray, verify- ing perfect fit of the all ceramic crown onto the implant. Fig.25. Adaptation of the final prosthesis onto the mature soft tissues, two months after sur- gery. Fig. 18. Preoperative and im- plant impressions, bite registra- tions and silicone keys, right after surgery. Fig. 21. The Mutually Protected Occlusion. Fig. 26. Final Full Contour ZIR- CONIA prosthesis on implants. Fig. 23. The Passive Abutment. nium machine-cut interfacial component/cylinder, offsets all the 3D inaccuracies, provided that the implant model is accu- rate. The passive abutment is cemented by the dental techni- cian onto the fitting surface of the prosthesis, in the lab. The master implant model is used as a blueprint for the cementation. Based on our experience over the past 15 years of using pas- sive abutments, the metal try-in procedure is not needed, thus speeding up the fabrication of the final prosthesis. 3)Placement of the Permanent Teeth One week after the implant sur- gery the patient returns for the placement of the permanent teeth. The temporaries are removed, the prosthetic platform of the implants is cleaned, dried and immediately the permanent teeth are screwed onto the im- plants. There is a big benefit having to work only with “one piece screw retained” (Fig. 24) prosthesis. There are no multiple custom abutments to be positioned first, the retrievability of the “one piece prosthesis” makes adjust- ments much easier, there is no excess cement to deal with dur- ing cementation that can cause significant complications if left accidentally under the imma- ture tissues. Fitting of the prosthesis is as- sessed with x-rays. Like with the temporary teeth all parameters (esthetic, phonetics, occlusion) are checked again and adjust- ments are made. The prosthetic screw is torqued down to 32Ncm and the prosthetic access holes are obturated. A night guard is provided and the patient is in- structed to use it every night. Oral hygiene instructions are demonstrated and their impor- tance is emphasized. Follow up Two months later the osseoint- ergration of the implants is ra- diografically and mechanically evaluated. In case of soft tissue recession, a pick up impression of the prosthesis is done. A new soft tissue model is fabricated and the dental technician can add porcelain accordingly (Fig. 25). The patient is followed up every six months for the first two years and thereafter according to his/her oral hygiene level. Complications The majority of the prosthodon- tic complications are porcelain fractures/chipping. These are easily repaired by removing the teeth and rebaking the porce- lain. CAD/CAM Advancements Recently in order to eliminate this problem, at SameDay Den- tal Implants® Clinic, CAD/CAM full contour zirconia screw re- tained implants prostheses are used in selected patients (Fig. 26). Only the front 6 teeth are layered (buccaly) with porcelain to optimize esthetics and pas- sive abutments (titanium) are utilized to eliminate zirconia to titanium wear problems. Even though zirconia is a tech- nique sensitive material, the first results (one year) are very promising. However, only time will tell, if zirconia will be the material of choice. The advance- ments in digital impressions and CAD/CAM technology will fur- ther reduce the manufacturing time but most importantly will increase the accuracy and qual- ity of the dental prostheses. Conclusion By using tapered angled im- plantsaswellaswideimmediate molar replacement implants in a prosthetically driven fashion it is possible in most cases to avoid bone grafts, achieve high pri- mary stability and treat patients with implants and passively fit- ting, screw retained teeth all in the same day (Fig 27). This reduction in treatment time, immediate function and cost saving leads to high patient satisfaction and increased treat- ment acceptance by patients.