1.0 BASIC INFORMATION FOR SURGICAL PROCEDURES THE NEODENT IMPLANT SYSTEM IMPLANT DESIGNS 9

Transcription

1 SURGICAL MANUAL

2 CONTENTS 1.0 BASIC INFORMATION FOR SURGICAL PROCEDURES THE NEODENT IMPLANT SYSTEM Overview CM Implant WS Facility IMPLANT DESIGNS Surface Neoporos Acqua Implant Options Drive CM Titamax CM EX Titamax CM Alvim CM Facility Titamax WS Options of thread according to the implant design INDICATIONS AND CONTRAINDICATIONS PREOPERATIVE PLANNING Implant positioning and periimplant tissue Mesiodistal Positioning of the implant Examples of single tooth gaps 18 2

3 Examples of multiple tooth gaps Buccallingual implant position Apical coronal implant position Planning aids Space Planning Instrument as a diagnosis and help for implant placement Direction Indicator pins for the diagnosis of adjacent bone Surgical drill template or guide Xray templates Softwares for implant planning SURGICAL PROCEDURES Implant bed preparation Basic implant bed preparation For conical Alvim and Drive implants For cylindrical Titamax implants For narrow Facility implants Fine implant bed preparation Pilot Drill Tap Drill Example of fine implant bed preparation Neodent implant packaging Options for drilling Placing the implant Place the implants with the contra angle Place the implants by hands Finalize the implant positioning with the wrench 45 3

4 6.4. Soft tissue management Two stage/ submucosal healing Transmucosal healing: One stage or Immediate loading Transmucosal healing: One stage Overview of the healing abutments Overview of the CM Abutments and corresponding Healing Caps HEALING PHASE ABUTMENT TRY IN KIT PROSTHODONTICS GENERAL GUIDELINES NEODENT KITS Sterilization Cleaning and care of instruments 57 BIBLIOGRAPHIC REFERENCES 58 4

5 1.0 BASIC INFORMATION FOR SURGICAL PROCEDURES The Modern Implantology era, based over clinical results on osseointegration, was originally published on English based journals in 1977 (1). Since then Dentistry had important changes and the treatment plan of a patient today usually offer implant retained and/or supported prosthesis as an affordable and reliable solution. The number of oral implants placed are rapidly increasing over the years (2, 3) and this treatment concept requires specific skills and knowledge, as the surgeon s learning curve, that are relevant for the results (4). Based on this facts the present guide aims to provide to dental practioners and specialists basic information and steps regarding the planning, surgical procedures and options of treatment. This guide does not replace the instructions for use (IFU) of each product, which can be found in our website: THE NEODENT IMPLANT SYSTEM 2.1 Overview The Cone Morse (CM) Neodent implant system offers 6 types of different implant designs, threads, apex and two types of surface treatment. Neodent s philosophy is to offer one implant solution adapted to the proper indication, which is bone density, quantity and surgical technique. All implants can be installed with the NEODENT surgical kit, except for the Facility system that requires a specific surgical kit. Procedures are standardized and have straightforward steps. CM WS Facility FIGURE 1. Neodent options of implants according to their indication. 5

6 2.2 CM Implant All of which have Morse taper connection. The CM implants (Drive, Alvim, Titamax EX and Titamax cortical) have an internal total angle of 11.5 and the same prosthetic connection dimension regardless the implant diameter (figure 2). The platform switch concept (7) from Neodent CM has proven biological stability of the periimplant tissue, specially when the implants are placed 12mm sub crestally (8, 9, 10, 11, 12, 13). FIGURE 2. Neodent CM implant connection has one width regardless of the implant diameter. 2,5mm 11,5º 4,1mm FIGURE 3. Neodent CM has a deep connection inside the implant designed to enhance the contact area between implant and abutment. 6

7 The Neodent conical connection has an internal hexagon as an index in its bottom called Exact. Exact is used for implant surgical placement and the repositioning of prosthetic parts when working at the implant level. FIGURE 4. Internal index as a hexagon created to surgically drive the implant and to proceed with the implant impression during the prosthetic phase. 2.3 WS WS (short implants) is a complementary line of cone Morse implants, suitable for special areas. WS Implants also feature an internal angle os 11.5, but different internal diameter and length. Therefore, a special line of abutments is required when working with these implants. They are indicated as an alternative for posterior free ended partially edentulous. 3,0mm FIGURE 5. WS implant connections are similar and compatible. 7

8 2.4 Facility Facility Implants also have a cone Morse connection, but with an internal angle of 5. They are the narrowest implants offered by Neodent and their abutments are placed through friction. Their use is indicated to the upper lateral incisors and lower incisors areas. FIGURE 6. Facility is the narrowest implant offered in the system and its abutments are placed through friction. The system has a full portfolio, adapted to the bone density/quality and patients needs. Implant Diameter Titamax Titamax EX Alvim Drive WS Facility TABLE 1. Offer of diameters according to the implant design. Implant Lenght , Titamax* Titamax EX Alvim * Drive WS* Facility TABLE 2. Options of length according to the implant design. * Available with Neoporos surface 8

9 3.0 IMPLANT DESIGNS Neodent CM implants are classified according to their macro design, thread features, apex and microroughness. APEX IMPLANT PROSTHETIC BODY CONNECTION CM Drive Titamax Alvim Drive Titamax Titamax EX Alvim FIGURE 7. General feature of the Neodent implants. 3.1 Surface Neodent implants are offered in two types of surface treatment as presented below. The decision about each surface is driven by the clinical indication Neoporos Neoporos is a special process created for the Neodent implant surface. Firstly the roughness is obtained through sandblasting, where the size of particles and the pressure are adapted to the implant design. Posteriorly blasting, the implants are acid etched in specific conditions. Figure 8 represents this procedure. Machined Sa= 0.26 µm Sand blasted Sa= 0.67 µm Sand blasted + Acid etched Sa= 0.93 µm FIGURE 8. Physical manufacturing process of Neodent Treatment surface 9

10 FIGURE 9. Micro ( μm) and macro (1530 μm) structure for Acqua & Neoporos FIGURE 10. Confocal laser scanning microscopy in the thread region (15) Acqua Acqua is a hydrophilic implant with the titanium surface having the valence shell changed. The physical process from Neoporos is performed over the implants, however Acqua is manufactured in a especial area of the Neodent production where all implants are packaged and stored in a liquid environment, avoiding contact with the atmosphere. This isolation results in wettability (presenting contact angle <5 ) and an active physicochemical surface (with positive ions). Implants with Acqua surface are indicated for implant placement in grafted areas, combined with grafting procedures, post extraction and sites of poor bone density (17,18). Surface Comparison Hydrophobic Surface (conventional). Acqua Hydrophilic Surface. Note: XPS measurements on Neoporos and Acqua Surfaces Neoporos (Atom%) Acqua (Atom%) Oxygen O Titanium Ti Nitrogen N Carbon C 55.9 ± ± ± ± ± ± ± ±

11 3.2 Implant Options Drive CM (1) Offered as Acqua or Neoporos surfaces; (2) Tapered implant with internal conical body; (3) Cervical conicity with microthreads; (4) Main threads are square shaped with a 2.2mm thread pitch; (5) Double threaded implant; (6) Reverse cutting chambers distributed across the implant body; (7) Bottom thread with sharp edge; (8) Rounded apex; (10) Indicated for bone types III and IV and implant immediate placement postextraction; (11) Same prosthetic connections for all diameters; (12) Implant should be positioned 12mm below bone level for better results (8, 9, 10, 11, 12, 13) ; (13) Drill speed: rpm; (14) Implant insertion speed: 30 rpm; (15) Maximum torque for placement 60 N.cm Titamax CM EX (1) Offered as Acqua or Neoporos surfaces; (2) Parallel wall (cylindrical) implant; (3) Triangular (or pyramidal) threads with 1.2 mm of thread pitch; (4) Double threaded implant; (5) Implant apex adaptad to be inserted in a 2.0mm osteotomy; (6) Indicated for bone types III and IV and for areas with narrow bone areas where under preparation is indicated; (7) Contra indicated for immediate placement post extraction; (8) Same prosthetic connection for all implant diameters; (9) The implant cervical diameter is the same as the body diameter; (10) Implant should be positioned 12mm below bone level for better results (19) ; (11) Drill speed: rpm; (12) Implant insertion speed: 30 rpm; (13) Maximum torque for placement 60 N.cm Titamax CM (1) Only offered as NeoPoros surface; (2) Parallel wall (cylindrical) implants; (3) Triangular (or pyramidal) threads with 1.2 mm of thread pitch; (4) Double threaded implant; (5) Self tapping chambers; (6) Indicated for bone types I and II or grafted areas as bone block; (6) Same prosthetic connection for all implant diameters; (7) The implant cervical diameter is the same as the body diameter; (8) Final pilot drills are highly recommended to be used as the implant should be positioned 12mm below bone level for better results (19) ; (8) No tap is needed during placement; (9) Osteotomy drill speed: rpm; (10) Implant insertion speed: 30 rpm; (10) Maximum torque for placement 60 N.cm 11

12 3.2.4 Alvim CM (1) Offered as Acqua or Neoporos surfaces; (2) Tapered implant; (3) Trapezoidal threads with 1.2 mm of thread pitch; (4) Double threaded implant; (5) Conical apex with low active chambers designed to optimize secondary stability; (6) Indicated for bone types III and IV and implant immediate placement postextraction; (7) Tap is needed if indicated for bone types I and II; (8) Same prosthetic connection for all implant diameters; (9) The implant cervical diameter is the same as the body diameter; (10) Final pilot drills are highly recommended to be used in bone types I and II; (11) Implant should be positioned 12mm below bone level for better results (19) ; (12) Drill speed: rpm for bone type I and II; (13) Drill speed: rpm for bone type III and IV; (14) Implant insertion speed: 30 rpm; (15) Maximum torque for placement 60 N.cm Facility (1) Offered as Acqua or Neoporos surfaces; (2) narrow implant with 2.9mm in diameter with a pure cone Morse frictional lock connection; (3) Double threaded implant; (4) Recommended for lateral upper incisors and lower incisors; (5) Indicated for bone types I, II, III and IV; (6) Tap is needed if used in bone types I and II; (7) The implant cervical diameter is the same as the body diameter; (8) Implant could be positioned 12mm below bone level when possible; (9) Requires exclusive instruments and line of prosthetic components; (10) Drill speed: 500 a 800 rpm; (11) Implant insertion speed: 30 rpm; (12) maximum torque for placement 45 N.cm Titamax WS (1) Only offered with Neoporos surface; (2) Parallel wall (cylindrical); (3) Triangular (or pyramidal) threads with 0.6 mm of thread pitch; (4) Single threaded implant due to the short implant length; (5) Apex with self tapping chambers; (6) Indicated for bone types I and II; (7) Alternative for posterior free ended partially edentulous; (8) The implant cervical diameter is the same as the body diameter; (9) Final pilot drills are recommended depending on the implant final positioning; (10) Implant could be positioned 1 mm below bone level when possible; (11) Requires exclusive instruments and line of prosthetic components; (12) Premounted fixture; (13) Osteotomy drill speed : 200 a 300 rpm; (14) Implant insertion speed: 30 rpm; (15) Maximum torque for placement 60 N.cm 12

13 Implant Bone Density Bone Type I Bone Type II Bone Type III Bone Type IV Drive CM Acqua Drive CM Titamax CM EX Acqua Titamax CM EX Titamax CM Alvim CM Acqua Alvim CM Facility Acqua Facility * * * * * * * * Titamax WS TABLE 3. Implants indication table according to bone types (Lekholm and Zarb, 1985) *Tap is required. 3.3 Options of thread according to the implant design Drive: 13

14 Titamax: Alvim: 14

15 4.0 INDICATIONS AND CONTRAINDICATIONS Neodent implants are produced in titanium Grade 4 coldworked in order to enhance the mechanical strength of the fixtures, according to ASTM F67. Facility Implants feature titanium alloy, according to ASTM F136. Table 4 presents specifics distances related to it. Implant Distinctive Features Minimal ridge widht* Minimal gap widht** Avaible Lenghts Bone type III and IV; postextraction 5,5mm 5,5mm 8/10/11.5/13/16/18 mm Drive Bone type III and IV; Promotes high bone expansion due to subosteotomy, ideal for narrow bone width 5,5mm 5,5mm 9/11/13/15/17 /19 mm*** Titamax Ex Bone type I and II and areas grafted with blocks; self tapping. 5,5mm 5,5mm 7/8/9/11/13/15/17mm Titamax** Bone type III and IV; when combined to a tap drill: bone type I and II; postextraction. 5,5mm 5,5mm 8/10/11/13/16 mm Alvim Bone type III and IV; when combined tap drill: bone type I and II; upper lateral incisors and lower incisors in narrow spaces. 4,9mm 4,9mm 10/12/14 mm Facility WS*** Bone type I and II; free end partially edentulous in the posterior area. 6,0mm 6,0mm 5/6 mm * Minimal ridge width: Minimal buccallingual ridge width, rounded off to 0.5 mm. ** Minimal gap width: Minimal mesialdistal gap width for a singletooth restoration, between adjacent teeth, rounded off to 0.5 mm. *** Only available as Neoporos. To obtain more information about indications and contraindications related to each implant, please refer to the corresponding instructions for use. Instructions for use can also be found on ifu.neodent.com.br 15

16 5.0 PREOPERATIVE PLANNING 5.1 Implant positioning and periimplant tissue The implant positioning is the key to obtain the correct prosthetic restoration, and is the basis for the surgical planning. An adequate communication amongst the patient, dentist, surgeon and lab technician is essential for reaching the desired prosthetic result. To establish the correct planning, with the correct spatial position, choosing the ideal implant design (diameter and length), number and distribution of implants, it is recommended to: Perform a waxup on the patient s study cast; Define the edentulous space to be restored; Define the type of superstructure; Do CT scan and radiographic exams. The waxup can then be used to fabricate the radiographic and/or surgical template, and be used as a temporary restoration. Physiological occlusion is determinant to the implant success in short and long term. Immediate loading procedures couldn t be performed in patients with problems in occlusion. Notes: The implant abutments should always be loaded axially, and the long axis of the implant aligned with the cusps of the opposing teeth. Extreme cusp formation should be avoided, since it may lead to unphysiological overloading. The diameter, type, position and number of implants should be individually decided for each patient, taking into account anatomy and the prosthetic space, bad positioned or angled teeth should be considered and analyzed. The recommendations presented here should be considered as basic guidelines for correct biological healing, adequate restorations and that the patient may have the conditions for efficient hygiene of the area. The restoration design has a strong impact over occlusion and hygiene and it must be taken in consideration. The final response of the hard and soft tissues is highly influenced by the position of the abutment, therefore the tridimensional positioning of the implant needs to be studied, being these: Mesiodistal Bucco lingual Apical Coronal 16

17 5.1.1 Mesiodistal Positioning of the implant The available mesiodistal bone is an important factor when choosing the implant diameter and quantity. It is the distance between implant to teeth and implant to implant when multiple implants are required. The reference point is to measure the larger mesiodistal width of the implant, usually in the cervical area. Generally implants require a minimum of adjacent bone of around it. The distances shown here are rounded off minimum 0.5mm of bone. The basic rules to be followed are: Rule 1 Ideally, the distance of CM implants to adjacent teeth is at least between the implant widest portion and the teeth, both on the mesial and distal aspects. Rule 2 As implants requires at least of adjacent bone, the distance to other implants is minimum 3mm. 17

18 Examples of single tooth gaps For single tooth restorations, the implant should be installed in the middle of the gap. The following example shows how to follow Rule 1. For all Neodent CM implants, the gap size needs to be considered for the selection of the implant diameter. Aiming to place an implant in the gap width according to the Rule 1, the following aspects can be used as an approximation: FIGURE 10. The distance between adjacent teeth is approximately 1mm more at the bone level because of the tooth anatomy and the interproximal contact point when compared to the real bone gap width (two times 0.5mm). So, applying Rule 1, the gap width must be 2mm wider than the implant diameter. 18

19 Implant Diameter D (mm) Gap width A (mm) Distance between adjacent teeth at bone level B (mm) Implant Tooth Distance E 1 (mm) 2,9 3,5 3,75 4,0 4,3 5,0 6,0 Rule *Rule 1 applied on both implant sides 4,9 5,5 5,75 6,0 6,3 7,0 8,0 D + 2mm 5,9 6,5 6,75 7,0 1,5 7,3 8,0 9,0 D + 3mm* Examples of multiple tooth gaps The following examples show how Rules 1 and 2 are applied to multiple tooth gaps. The measurements are made at crestal bone from the adjacent tooth to the center of the implant and between implant centers. Implant center has to be taken in consideration because of the initial drill during osteotomy. The minimum distance of 3mm must be followed between implant shoulders (Rule 2) that is important for flap closure, to avoid proximity of secondary components and adequate space for maintenance, emergence profile of the restoration and oral hygiene. 19

20 Implant Diameter D1 (mm) 2,9 Implant Diameter D2 (mm) 2,9 A B C L 3,0 5,9 3,0 11,8 Implant Tooth Distance E 2 (mm) 3,5 3,5 3,3 6,5 3,3 13 3,75 4,0 3,75 4,0 3,4 3,5 6,8 7,0 3,4 3,5 13,5 14 3,0 4,3 4,3 3,7 7,3 3,7 14,6 5,0 5,0 4,0 8,0 4,0 16 6,0 6,0 4,5 9,0 4,5 18 Normally clinical cases have different Gaps and then D1/D2 can be different in order to adapt the implants to every situation. Looking for a simpler rule, the dentist has to take in consideration that every implant requires a minimum of 1.5 mm of adjacent bone, regardless of the implant diameter. So during the planning it must be considered that independently of the implant diameter, it is important to have the minimum of 1.5 mm of mesial and distal peri implant bone. 1,5mm 20

21 5.1.2 Buccallingual implant position The facial and palatal bone layer must be at least 1mm in thickness so as to ensure stable hard and soft tissue conditions. The minimum buccallingual width of each implant diameter is shown in table 4. Within this limitation, a restorationdriven buccallingual implant position and axis should be chosen so that better restorations are obtained. Also, the surgeon needs to know if the plan is to do a screw or cementretained prosthesis. Caution: Techniques for bone augmentation are highly advisable for ridges where the orofacial bone wall is 1mm or less or where there is bone missing on one of the sides. These procedures should be conducted only by dentists with advanced experience in grafted bone regeneration (GBR). (A) (B) FIGURE11: Example of screwretained implant positioned (A) and cemented crown (B), where there is access to the retainaly screw Apical coronal implant position CM Neodent implants were designed for a 2mm subcrestal positioning in order to optimize stability of hard and soft tissues and also for better aesthetic results of the restorations, especially in the front area (6,7,8,9,10,12). In a scalloped situation, place the implant at the bone level according to the inner bone wall, depending on the clinical case some osteotomy has to be made as abutments have limits in transmucosal height. The implant should be fully covered of bone or grafted with biomaterials to avoid dehisence of the titanium. For further information about the implant positioning, please refer to specific basic literature. 21

22 5.2 Planning aids Space Planning Instrument as a diagnosis and help for implant placement By using the 7/9mm Space Planning Instrument in the patient s mouth or on a model, an initial analyses of the spatial relations can be obtained aimming to select the implant diameter and prosthetic reconstruction. The Space Planning has two tips with 7 and 9 mm in width and a mark exactly in the middle (of 3.5 or 4.5 mm), it works as a reference for the surgeon when placing implants respecting the 1.5 mm rule of minimum adjacent periimplant bone. FIGURE 12: Space Planning Instrument for diagnosis of the spaces and implant placement. FIGURE 13: Detail on the Space Planning Instrument tip of 7 mm for analysis of the gaps, the mark is on. The 1.5 mm rule is important for implant placement according to the teeth position, implants and anatomical structures as nerves, for example, the Space Planning Instrument can help positioning an implant closer to a foramen. FIGURE 14: Using the Space Planning Instrument for positioning the drills for implant placement. 22

23 5.2.2 Drill Positioner pins for the diagnosis of adjacent bone Every Drill Positioner pin in Neodent has different designs aiming to analyze the quantity of bone around an osteotomy. All pins have: (1) lower, (2) medium and (3) upper part. Lower Medium Upper FIGURE 15: The pin lower (2 mm), medium (implant diameter) and upper part (last drill from the basic osteotomy). The inferior part of all pins has 2.0 in diameter to be adapted after the first osteotomy. The medium part of the pin has the respective diameter of the implants. All diameters are color coded as presented in figure 09. Diameter Indicators Medium Upper 3,5 2,8 3,75 3,0 3,3 4,0 4,3 3,6 5,0 4,3 5,0 4,3 6,0 6,3 TABLE 4: Options of color coded pins. The medium part of the pins has the same width as the implants, based on the values written at the upper part. 23

24 The upper part of each Drill Positioner has the same diameter of the last drill before implant placement, according to the osteotomy protocols from Neodent. The Drill Positioner allows the surgeon to check the adjacent bone as illustrated below. 3,75 3,0 FIGURE 16: Drill Positioner inserted after the initial drill and adapted inside the last osteotomy based on drill protocol. It helps the analysis of the remaining adjacent bone when positioned. Also, there are Drill Positioners that allow the surgeons to evaluate the abutment angle before implant placement. These pins are offered in two angles (17o and 30o) and are inserted in the 2.0 mm osteotomy. FIGURE 17: Angled Direction Pins for abutment selection. 24

25 Notes: Neodent Titanium tweezers have a rule in their tips helping surgeons in analyzing all edentulous area. FIGURE 18: Titanium tweezers calibrated in millimeters Surgical drill template or guide A custom made surgical drill template manufactured by the lab technician facilitates the preparation of the implant bed and enables precise use of the cutting instruments. The planning basis for fabricating this template should be the desired prosthetic result. Models can be drilled with 2.0mm drills at the implant position and guides for sleeves of 2.0mm in diameter are adapted over it. Wax or vacuum formed templates are built with the sleeves engaged inside. After the template asepsis, it s used during the surgery and its sleeves will guide the initial drilling during the surgical procedure. 2,0 2,0 2,0 FIGURE 19: Sleeves of 2.0 mm in diameter and guides to be adapted in the patient`s model. 25

26 5.2.4 Xray templates The Xray templates are used for measurement and comparison, and assist in the planning phase since they assist the dentist in selecting the suitable implant type, diameter and length. The NEODENT Xray template has the following implants printed: Titamax; Alvim; Drive; Facility; WS. In the two dimensions: 1:1 to be used on 1:1 Periapical radiographs and 1:1 CBCT scans, and can be superimposed due to the transparency of the template. 4:1 the images of the implants are 25% larger than the normal size, and can be used on Panoramic radiographs that came with a 25% distortion. Due to the digital Panoramic machines, these distortions are slowly being adapted. FIGURE 20: X Ray template for CM Neodent implants Softwares for implant planning Neodent has partnership with the main softwares companies for implant analysis (for example codiagnostix ) and they can be used as an important tool for previous treatment plan. 26

27 6.0 SURGICAL PROCEDURES 6.1 Implant bed preparation Diameter, position and number of implants should be selected taking into account anatomy and spacial circunstances. The measurements should be in accordance to the basic guidelines. Basic implant bed preparation involves ridge preparation and twist drilling with water cooling, for which the diameter and the design (if cylindrical or conical) of the selected implant determine the instruments to be used. Fine implant bed preparation involves profile drilling and tapping, for which the type of implant and bone density determine the instruments to be used. Steps Instrumentation 1. Basic implant bed preparation Ridge preparation Initial drill Twist drilling Twist drill 2.0mm; Direction indicator pin; Depth gauge 2. Fine implant bed preparation Conical or cylindrical drills and profile drilling Tapping Drills shape to be defined according to the implant design and drill step by step and diameter according the implant width Tap for Alvim or Facility in bone type I and II Note: Titamax, Titamax EX, Alvim, Drive and WS implants can be placed using the same kit, where the Alvim and Drive implants have conical drills for the implant bed preparation and Titamax and WS also have their specific drills. WS implants of 6.0mm in diameter request extra drills present at one cassette for WS. The Facility implants have their own instrument kit as well Basic implant bed preparation After opening a flap and exposing the bone, the preparation of the alveolar ridge begins. Once the position of the implant has been decided previously and with surgical guide aids, the cervical cortical layer is perforated with the initial drill (step1) and verified visually for its spatial positioning. The indicated rotations per minutes (rpm) for drilling relies basically on the bone density, where in bone type I and II is applied rpm and type III and IV rpm. Although short implants WS request a drilling protocol of rpm, regardless of the bone density. This initial perforation works as a guide. After this, the 2.0mm twist drill is used to reach the desired depth for the chosen implant, always remembering to consider the 12 mm sub crestal insertion of the CM implant. Then a next drill is used to prepare the osteotomy following a sequence according to the implant type and diameter, as chosen in the preoperative planning. All drills are adapted to contra angles according to the ISO Dental rotary instruments Shank. 27

28 Step 1 Preparing the implant site and initial drill Carefully reduce and smooth to provide a flat bone surface before marking the position of the implant with the initial drill. Use the initial drill about 57 mm with the rpm in accordance to the bone density. For WS implants, this initial drilling should be very carefully, about 34mm and under rpm. Note: the reduction/preparation of the bone needs to be considered in the preoperative planning since it influences the choice of the implant diameter and length. Step 2 Check the implant axis After using the initial drill, check the implant axis using the Direction Indicator pins. Implant diameters and adjacent bone can be rechecked as described in Step 3 Twist drill 2.0 Use the 2.0mm twist drill to reach the planned preparation depth. The use of the surgical probe is recommended to control the depth. Note: 1 a periapical Xray at this point would be recommended for checking vertical bone availability, or checking the axis in relation to adjacent roots, for example. The Direction Indicator pin is fully inserted into the drilled area, allowing to visualize the drill hole in relation to the anatomical structures. 2 the 2.0 twist Neodent drill has an active tip that can be used as an initial drill. This can be performed in situations were there is a flat bone ridge and so the use of the initial drill can be avoided. 28

29 For conical Alvim and Drive implants Step 4 Conical Drill 3.5 The tip of the tapered drill 3.5 adapts in the 2.0 mm osteotomy and so the prepared bone guides this drilling. This is the last basic drill step for the conical implants of 3.5 mm. Note: an Xray at this point would be recommended for analysis of the bone availability or to check the axis in relation to adjacent roots. A radiographic pin of the 3.5 implant is inserted into the drilled area. Step 5 Conical Drill 4.3 The tip of the tapered drill 4.3 adapts in the 3.5 mm osteotomy, guiding the drilling. This is the last basic drill step for the conical implants of 4.3 Note: an Xray at this point would be recommended for analysis of the bone availability or to check the axis in relation to adjacent roots. A radiographic pin of the 4.3 implant is inserted into the drilled area. Step 6 Conical Drill 5.0 The tip of the tapered drill 5.0 adapts in the 4.3 mm osteotomy, guiding the drilling. This is the last basic drill step for the conical implants of 5.0 Note: an Xray at this point would be recommended for analysis of the bone availability or to check the axis in relation to adjacent roots. A radiographic pin of the 5.0 implant is inserted into the drilled area. 29

30 Note 1: all Alvim drills have similar marks referred to each implant lenght, regardless of the drill diameter. Note 2: all drills are available in short and some are available in a long version. Note 3: Due to its function, alvim drills are maximum 0.5mm longer than the implant. This additional length has to be planned before the surgery For cylindrical Titamax implants For Titamax Ex Step 4 Implant placement Titamax EX implants are designed to undersized osteotomy. So regardless of the implant diameter (Titamax Ex is offered as 3.5, 3.75 and 4.0), the implant can be placed after the 2.0mm drill. Note: In cases where there is a thick cortical layer (over 3 mm) the 2.8 drill can be used about 1/3 of the planned implant length in order to reduce the stress over this area. For cylindrical implant Titamax 3.5 Step 4 Twist drill 2.8 This is the last drill basic step for the Titamax 3.5 as this implant design avoids the use of tap drill. Although fine preparation is requested in bone types I and II. Widen the implant bed to 2.8mm, you may correct the positioning if necessary, and reach the final preparation depth. Check the preparation with the Direction Indicator pin 3.5 as described in

31 For cylindrical implants Titamax and WS Step 5 Pilot drill 2/3 Use the 2/3 pilot drill to widen the initial portion of the implant bed in situations where the drill 3.0 is requested as a next step. Insert the drill until the mark is reached. For cylindrical implants Titamax and WS Step 6 Twist drill 3.0 After the preparation with the pilot 2/3 drill, widen the whole implant bed to 3.0mm and check with the 3.75 Direction Indicator pin as described in drill can be used as a last basic step drill or an intermediate drill of a sequence, depending on the implant diameter chosen to be placed. Note: This is the last basic drill step for the Titamax implants of 3.75 mm as this implant design avoid the use of tap drill. Although fine preparation is requested in bone types I and II. For cylindrical implants Titamax and WS 4.0 Step 7 Twist drill 3.3 This is the last drill basic step for the Titamax and WS implants of 4.0mm as these implant designs avoid the use of tap drill. Although fine preparation is requested in bone types I and II. Widen the implant bed to 3.3 mm, you may correct the positioning if necessary, and reach the final preparation depth. Check the preparation with the Direction Indicator pin 4.0 as described in

32 For cylindrical implants Titamax and WS Step 7 Pilot drill 3.0/3.75 Use the 3.0/3.75 pilot drill to widen the initial portion of the implant bed in situations where the drill 3.8 is requested as a next step. Insert the drill until the 2 nd mark is reached. For cylindrical implants Titamax and WS Step 8 Twist drill 3.8 Widen the implant bed to 3.8 mm as this step is required in the drill sequence of implants with 5.0 and 6.0 in diameter. For cylindrical implants Titamax and WS Step 9 Twist drill 4.3 This is the last drill basic step for the Titamax and WS implants of 5.0 mm as these implant designs avoid the use of tap drill. Although fine preparation is requested in bone types I and II. Widen the implant bed to 4.3 mm, you may correct the positioning if necessary, and reach the final preparation depth. Check the preparation with the Direction Indicator pin 5.0 as described in

33 For cylindrical implants WS Step 10 Pilot drill 4.3/5.3 Use the 4.3/5.3 pilot drill to widen the initial portion of the implant bed in situations where the drill 5.3 is requested as a next step: for implants of 6.0 in diameter. Insert the drill until the 2 nd mark is reached. For cylindrical implants WS Step 11 Twist drill 5.3 This is the last drill basic step for the WS implants of 6.0 mm as this implant design avoids the use of tap drill. Although fine preparation is requested in bone types I and II. Widen the implant bed to 5.3 mm and reach the final preparation depth. Check the preparation with the Direction Indicator pin 6.0 as described in Note: all Twist drills have similar marks referred to each Titamax implant length, regardless of the drill diameter 33

34 For narrow Facility implants Each Facility implant has one specific drill according to their lengths. Depending on the chosen implant, each drill has a mark at the bone level or a reference at 2 mm over its length. Note: There are X ray positioners for checking the Facility implant axis The following sequences summarize the use of instruments for the basic bed preparation according to the implant diameter and type. Note: all Twist drills have similar marks referred to each Facility implant length. 34

35 Instruments for basic implant bone preparation Diameters (mm) Step Art. n Product Max RPM Image Ø 3.5 Ø 4.3 Ø Preparing the implant site and initial initial drill* Initial drill Check the implant axis Direction Indicator Conical drill 2.0* Tapered drill Tapered drill Conical drill Direction Indicator 2.8/ Tapered Xray positioner Helix Pilot Drill 2.8/ Pilot Drill 2.8/ Optional Tapered drill Conical drill Direction Indicator 3.6/ Tapered Xray positioner Helix Pilot Drill 3.6/ Pilot Drill 4.3/ Optional Tapered drill Conical drill Direction Indicator 4.3/ Tapered Xray positioner Helix Pilot Drill 4.3/ Pilot Drill 4.3/ Optional * The sequence can start direct from drill 2.0 if the bone bed is flat. Titamax Ex Instruments for basic implant bone preparation Diameters (mm) Step Art. n Product Max RPM Image Ø 3.5 Ø 3.75 Ø Preparing the implant site and initial initial drill* Initial Drill Check the implant axis Direction indicator Twist drill 2.0* Twist Drill Twist drill 2.8** Twist Drill * The sequence can start direct from drill 2.0 if the bone bed is flat. ** Optional in cases of a thick cortical layer using about 1/3 of the planned implant length. 35

36 Titamax and WS Step Instruments for basic implant bone preparation Art. n Product Max RPM Image Diameters (mm) Ø 3.5 Ø 3.75 Ø 4.0 Ø 5.0 Ø Preparing the implant site and initial initial drill* Initial drill 1200 Image 2 Check the implant axis Direction Indicator Twist drill 2.0* Twist Drill Twist drill Twist Drill 2.8 Direction Indicator 2.8/ Pilot Drill 2/ Pilot drill 2/ Twist Drill Twist Drill Direction Indicator 3.0/ Pilot Drill 3.0/ Twist Drill Twist Drill 3.3 Direction Indicator 3.3/ Pilot drill 3.3/ Pilot drill 3.3/ Twist Drill Twist Drill Twist Drill Twist Drill Direction Indicator 3.6/ Direction Indicator 4.3/5.0 ** 11 Pilot drill 4.3/ Pilot drill 4.3/ Pilot drill 4.3/ Pilot drill 4.3/ Twist Drill Twist Drill Direction Indicator 5.3/ Pilot drill 5.3/ Pilot drill 5.3/ * The sequence can start direct from drill 2.0 if the bone bed is flat. ** This is the only Direction Indicator pin for WS implant. Note: All narrow parts of the drill positioner pin can be used for checking the implant axis as indicated in page

37 Facility Step Instruments for basic implant bone preparation Art. n Product Max RPM Image Diameters (mm) Ø 10 Ø 12 Ø 14 1 Preparing the implant site and initial initial drill* Facility Initial Drill Facility twist drill 2.0* Facility Twist drill Check the implant length Facility X Ray positioner 4 Facility drill Facility Drill Facility drill Facility Drill Facility drill Facility Drill * The sequence can start direct from drill 2.0 if the bone bed is flat Fine implant bed preparation The fine bed preparation encompasses (1) pilot drilling and (2) tapping, when needed. Instrumentation depends on the implant type, the implant diameter and the type of bone. Osteotomy in bone type I and II requires final pilot drills in because of the final implant positioning. Tap drills are only requested for the use of Alvim and Facility implants in areas of high bone density Pilot Drill Pilot drills are used to prepare the implant bed when widening from one twist drill to another in the basic drilling procedure. For fine bone preparation, pilot drills help in positioning the platform of the CM implant according to the bone bed, if at the bone level, 1, 2 or 3mm subcrestal in areas of a higher cortical layer is present. So usually they are only used in bone type I and II and indicated as optional in bone types IIIIV. Drive CM implants don t request the use of this drill because of its coronal design. The rpm used for the pilot drills is maximum mm subcrestal 2mm subcrestal 1mm subcrestal bone level FIGURE 21: Pilot drill for the fine implant bed preparation. It helps the implant coronal positioning in areas of bone with higher density: if bone level, 1, 2 or 3mm subcrestal. It is not necessity for Drive CM implants Tap Drill Tapping prepares the bed for a specific thread type. It is a step used for bone type I and II in order to keep the insertion torque in a desirable range. The tap drill is available for Alvim and Facility. Tapping is performed by coupling the tap to the contra angle or wrench. While for Facility it is indicated to be started by the contra angle and finalized with the wrench, for Alvim there are two options of use: with the contra angle handpiece and the WS implant driver (hexagon connection) or with the torque wrench (WS implant driver for torque wrench with a hexagon connection). The rpm should be of 1530 rpm when using a contra angle and a slow clockwise rotating movement for the use with wrench, for removing in the counterclockwise direction. The maximum torque of use should be 60 N.cm for the Alvim and 45 N.cm for Facility. FIGURE 22: Tap drills were engineered to be used in bone bed types I and II for Alvim and Facility implants. 37

38 ContraAngle FIGURE 23. Option for taping with Alvim. ContraAngle FIGURE 24. Options for taping with Facility. First start with the contra angle and finish with the wrench. 38

39 Example of fine implant bed preparation Here follows an example of fine bed preparation for an Alvim implant of ø 4.3 mm and length of 13 mm placed in bone type I or II, turning the use of taping and pilot drills necessaries. The steps described followed the basic implant bed preparation ( ). Step 1 Pilot Drill Perform the osteotomy with the conical drills and depending on the planned level for final implant positioning (bone level, 1 or 2 mm sub crestal), use the pilot drill for the implant placement. Step 2 Tapping the threads in dense bone Tap the full length of the planned implant with the Alvim tap drill. The following table summarizes the use of Pilot and Tap drills for the fine bone preparation. Facility tap drill can be used in contra angle and wrench. Instruments for basic implant bone preparation Implants Art. n Product Max RPM Image Titamax Titamax Ex Alvim Drive Facility WS Pilot drill 2.8/3.5 Pilot drill 3.0/3.75 Pilot drill 3.3/4.0 Pilot drill 3.6/4.3 Pilot drill 4.3/5.0 Pilot drill 5.3/6.0 Alvim tap drill 3.5 Alvim tap drill 4.3 Alvim tap drill 5.0 Facility tap drill 300 Ø3.5 Ø3.5* Ø3.75 Ø4.0 Ø5.0 Ø4.3 Ø4.3* Ø5.0* Ø5.0 Ø3.5** Ø4.3** Ø5.0** Ø2.9* Ø6.0 *Optional. ** Only in bone type I and II. Note: Neodent surgical drills can be used about 25 times in bone type III/IV and 20 times in type I/II since conditions of use and indications, as irrigation and rotation, are respected. Regardless of this suggestion of times for use, all drills have to be checked about their sharpening conditions. The cleaning of all drill has to be made one to one, avoiding mechanical contact of the blades during this procedure. 39

40 6.1.3 Options for drilling Neodent Alvim drills are offered as long (35 mm) or regular (43 mm) because of mouth opening limitations or due to drilling procedures between two teeth. In case of necessity a Drill extension can be used for other drills from the system. FIGURE 25. Options of Alvim drill length (35 mm and 43 mm long). FIGURE 26. Neodent drill extension, a 1.2 driver is used to tight the screw that open and retain the drills. The maximum torque of use should be 30 N.cm Neodent implant packaging The Neodent packaging was especially updated for easy handling and safe clinical procedures, delivering practicality from the housing of the implants to pickup and carrying to the implant bed. The characteristics of the implant such as type, diameter and length are easily identifiable on the on the outside of the package. Three peeloff labels are provided for the patient s treatment record and for communicating with the prosthodontics team. 40

41 Instructions on opening the implant package Step 1 Open blister and remove the vial, pouring it onto a sterile area Step 2 After breaking the sterility seal in the blister, hold the package and twist the cap to open. Note: for Acqua implants keep the vial upright to prevent the liquid from flowing out Step 3 Remove the implant from the tube lifting the cap, it has the implant attached. Note: for Acqua implants keep the vial upright to prevent the liquid from flowing out Step 4 While gripping the stand, remove the cap Step 5 Capture the implant using the contra angle hand piece. Grip the stand and rotate it in order to find the perfect seating between the drive at the contra angle and the implant. Make sure that the implant driver is fully seated into the implant Step 6 Transport the implant to the implant bed 41

42 Instructions on opening the conventional implant package Step 1 Open blister and remove the vial, pouring it onto a sterile area Step 2 After breaking the sterility seal in the blister, hold the pacakeg and pull the cap to open Step 3 The implant is holded at the tube Step 4 Capture the implant using the contra angle hand piece. Grip the stand and rotate it in order to find the perfect seating between the drive at the contra angle and the implant. Step 5 Make sure that the implant driver is fully seated into the implant and take it into position 42

43 6.3. Placing the implant CM Neodent implant were planned to start placing with the contra angle or by hands and finalize it with the wrench. The maximum speed recommended in the surgical motors is of 30 rpm and the torque of 45N.cm Place the implants with the contra angle The following instructions present the step by step of how CM Neodent implant is handled with the contra angle for placement. Step 1 Adapt the hand piece implant driver Hold the implant through its blister and attach the hand piece driver of the CM implant. All hand pieces drivers present a ring in the active tip in order to keep the implant stable during carrying. Implant drivers for torque wrench don t have the rubber for keeping implants in positioning for transport. Step 2 Place the implant with the contra angle into the implant bed. Place the implant into its final positioning with a maximum torque of 45 N.cm and 30 rpm turning it clockwise. Caution: Corrections of the vertical positioning through reverse rotations during the surgery may lead to decrease of initial/mechanical stability. 43

44 Step 3 Implant final positioning CM Neodent implants have an internal hexagon index called Exact. Make sure that the final implant positioning has one of the dots bucally positioned for prosthetic orientation. The implant drivers have six dots that coincide with the six sides of Exact. Position one of the dots on the driver buccally to ensure optimal placement of CM abutments indexed with Exact. A A CM Implant Driver Torque Wrench Long CM Implant Driver ContraAngle Note 1: There are three similar marks at 1mm intervals on the contra angle and the wrench implant carries. They will guide the depth of the implant final placement as following: 1st strip to 1 mm subcrestal, 2nd to 2 and the 3rd to 3 mm. Every full turn over the implants will result in: (1) 0.6mm in WS implants; (2) 2.2 mm Drive implants; (3) 1.4 mm in Alvim; and (3) 1.2 mm for all the other offered implants. 3mm subcrestal 2mm subcrestal 1mm subcrestal bone level Note 2: One important difference from the contra angle driver to the wrench one is that the contra angle driver has a rubber in the tip that keeps the implant in position. So wrench drivers are not indicated to transport the implant from the blister to the mouth Place the implants by hands CM Implant Driver ContraAngle Manual Implant Driver ContraAngle All sequence described below can be repeated by hands using the Manual implant driver Contra Angle (C.A.) instead of the contra angle. FIGURE 27. Any instrument for contra angle can be adapted in the Manual implant driver C.A. 44

45 Finalize the implant positioning with the wrench CM Implant Driver Torque Wrench Short CM Implant Driver Torque Wrench Long Remove the contra angle driver from the implant and adapt the driver for the wrench for final implant positioning and torque measurement. There are 2 options of wrench driver: long and short. First adapt the driver inside the implants with the fingers, and then engage the wrench over the driver. No wrench drivers should be used to transport the implant from a place to another, because the fixture may fall. Apply torque until the implant reaches its final position. All wrenches show the torques of 10/15/20/32/45 and 60N.cm, and torques over 60 N.cm are contra indicated. Caution: Corrections of the vertical positioning through reverse rotations during the surgery may lead to decrease of initial/mechanical stability Soft tissue management After implantation, the implant is closed with a cover screw or a healing cap (or healing abutment) to protect the implant. The surgeon can choose between submucosal or transmucosal healing and has all options available for soft tissue management made possible through a set of secondary healing components Two stage/ submucosal healing Cover Screw 2mm Cover Screw For submucosal healing (under a closed mucoperiostal flap) the use of a cover screw is indicated. A second surgical procedure is required for uncovering the implant and insertion of the desired secondary component. The NEODENT system has two cover screws, which are sold separately and are packed sterile, at implant level and 2.0 mm (above implant shoulder) because of the subcrestal positioning. 45

46 Step 1 Inserting the cover screw Ensure that the internal configuration is clean and bloodless. Pick up the cover screw with the 1,2mm screwdriver, the perfect fit secures the transport to the implant, and hands tighten the screw. Step 2 Close of the flap Adapt the flaps and suture with tension free sutures. 46

47 Note: Beware when using the 2.0mm cover screw as it can be exposed when placed in bone level implants in a thin mucosa area. The exposure of this piece permits mechanical contacts with removable dentures and it ll result in failure of the implant. Step 3 Regeneration period Remove sutures after approximately 7 days, or once they have lost their function and wait the regeneration phase of the bone. Step 4 Reopening and removal of cover screw Second surgery after the bone regeneration period for each implant/bone type, locate the implant with the aid of the surgical guide, Xrays or measurements, and with the desired technique, make an incision to reach the implant and remove the cover screw with the 1.2mm screwdriver 47

48 Step 5 Insertion healing abutment Rinse the exposed internal connection of the implant with sterile saline solution, insert a healing abutment (or an abutment if it can be chosen). Adapt the soft tissue and suture around the component. More info about healing abutments options can be found at #4.5. Step 6 Wound closure Adapt the soft tissue and suture around the component. 48

49 6.4.2 Transmucosal healing: One stage or Immediate loading A variety of healing caps and abutments are available in the Neodent CM system, shaping the softtissue during transmucosal healing right after implant placement. The components can be for intermediate use, where they are replaced with the definite abutment in the final restoration phase, or with the definite abutment with a temporary restoration. This phase can be defined as one stage surgery (if the healing abutment is chosen after the surgery) or immediate loading (if the proper abutment is chosen). The final implant placement torque determines the protocol to be defined. Proper and physiological patient s occlusion is determinant to define the protocol to be used. Patients without good occlusion are contra indicated for immediate loading protocols. Table 05 exemplify the criteria to be observed in order to select the correct protocol. Torque (N.cm) Healing Protocol General characteristics 20 N.cm Submucosal healing with selection of the cover screw Avoid exposure of the implant or cover screw. <20 to < 32 N.cm One stage/transmucosal healing with healing abutment selection Mechanical lateral load over the components is contra indicated. Periodontally compromised patients have to be previously controlled specially when any component is exposed at the patient oral cavity. 32 to 60 N.cm Immediate loading or abutment selection Mechanical lateral load over the temporary crowns is contra indicated. Patients need to present physiological or proper occlusion. Periodontally compromised patients have to be previously controlled when any component is exposed at the patient oral cavity. TABLE 05: Healing protocol according to torque level 49

50 Transmucosal healing: One stage Step 1 Healing abutment insertion after implant placement Ensure that the internal configuration is clean and without blood, insert the healing abutment with the 1.2mm screwdriver and hand tighten it. Step 2 Wound closure Adapt the soft tissue to the component and suture with tension free sutures. 50

51 6.5 Overview of the healing abutments The Neodent system has a variety of healing abutments, with different diameters and trasmucosal heights to suit to the definitive abutment. Therefore the correct choice is of utmost importance to have the right healing of the soft tissues, with controlled pressure and respect of the biological width. Basically there are different shapes of CM healing abutments to be adapted to the surgeon necessities: Ø of 3.3 or 4.5 Ø3.3 Ø mm 0.8mm Transmucosal heigth from mm Transmucosal Height 5.5mm 5.5mm Healing Abutments 6.5mm 6.5mm Aiming to select the proper abutment and to check the measurement of the remaining mucosa for component selection, there are 3 options of Height Measurer (for CM, WS and Facility) which are used adapted in the implants serving as a reference to select the right component. Height Measurer for Facility 4,5mm 3,5mm 2,5mm 1,5mm Height Measurer for CM 5,5mm 5,5mm 3,5mm 3,5mm 1,5mm 1,5mm 0,8mm The height of the components varies from 0.8mm to 6.5mm and should be chosen according to the gingival height. Since the internal design of the healing abutment is identical to that of the definite component, if the height of the healing cap was chosen too high, the soft tissue will heal accordingly. If the height of the definite component is not compatible, let s say lower, then it will exert a lot of pressure on the soft tissues and the patient will complain of pain due to compression. Therefore the choice of healing caps with the same width and transmucosal height are recommended. If the definite component needs to be changed, then the patient needs to be anesthetized and an adequate timing given for the soft tissue to readapt. 51

52 All Neodent healing abutments were strategically designed to create the correct emergence profile adapted to the margin of all abutments in a way it stays 0.9mm under the mucosa. 0,9mm 2,5mm Overview of the CM Abutments and corresponding Healing Caps Temporary abutment options Type Pro Peek Abutment Available Ø 6.0mm Abutment Transmucosal Heights 0.8mm 0.8mm 5.5mm 5.5mm Corresponding Healing Abutment Available Ø Transmucosal Heights 0.8mm 5.5mm 0.8mm 5.5mm 52

53 Screw retained CM options Type Miniconical Miniconical Microconical CM Abutment Equator (angled and exact) Available Ø 4.8mm 4.8mm 3.3mm 4.8mm 4.8mm 0.8mm 0.8mm 0.8mm 0.8mm 0.8mm Abutment Transmucosal Heights 5.5mm 5.5mm 5.5mm 5.5mm Available Ø 3.3mm Corresponding Healing Abutment Transmucosal Heights 0.8mm 5.5mm 0.8mm 5.5mm 0.8mm 0.8mm 5.5mm 0.8mm 5.5mm Cement retained CM options Type CM Anatomic abutment (and Exact) CM Anatomic abutment (and Exact) Universal Post (straight, angled and Exact) Universal Post (straight, angled and Exact) Available Ø 6.0 mm(buccal)/ 5.0 mm (lateral) 4.7 mm(buccal)/ 4.3 mm (lateral) 3.3mm Abutment Transmucosal Heights 0.8mm 0.8mm 5.5mm 5.5mm Corresponding Healing Abutment Available Ø Transmucosal Heights 3.3mm 0.8mm 0.8mm 5.5mm 5.5mm 53

54 Options for Facility Type Facility Anatomic abutment Microconical Equator Abutment Transmucosal Heights Corresponding Healing Abutment Transmucosal Heights Note 1: for Facility, the healing cap is also used as cover screw Screw retained WS options Cement retained WS options Type WS Mini Conical WS Abutment Type WS Universal Post Available Ø 4.8mm 4.8mm Available Ø Abutment Transmucosal Heights 0.8mm 0.8mm Abutment Transmucosal Heights 0.8mm Corresponding Healing Abutment Available Ø Transmucosal Heights 0.8mm 0.8mm Corresponding Healing Abutment Available Ø Transmucosal Heights 0.8mm Note 2: for WS, there is a specific cover screw and healing cap 54

55 7. HEALING PHASE The Healing protocol relies on: (1) Final placement torque of the implants or primarily stability measured with the torque wrench; (2) Type of bone when a minimum of 20 N.cm of torque is reached. More time is required when low values of torque are achieved, while a faster protocol can be used if torques are over 20N.cm. Also immediate loading procedures can be applied as described at the table XX in Situation Primarily stability 20N.cm Healing phase Primarily stability > 20N.cm Good bone quality (Type I and II) and adequate bone quantity At least 9 weeks (2 months) At least 17 weeks (close to 4 months) Cancellous bone quality (Type III and IV) At least 18 weeks (4 months) At least 26 weeks (6 months) 8. ABUTMENT TRY IN KIT To help choosing healing abutments and prosthetic components, NEODENT has developed a CM Prosthetic Try in Kit with the main possible combinations of width, transmucosal height, angulation and interoclusal height. It is a cassette composed with titanium pieces similar to abutments. 55

56 Every component has individual dimensions replicating important references for diagnosis of the spaces. The main references are: A) Diameter; B) Occlusal height of the prosthetic component; C) Height Mesuarement; A D) Angle (in Neodent it can be straight, 17 and 30 ). A B B D C C Straight Selection Abutment Angled Selection Abutment 9. PROSTHODONTICS GENERAL GUIDELINES Once this stage is reached, the definite post or abutment needs to be chosen for the final restoration. This step can be performed in the healed mucosa (submucosa healing, conventional protocol) or during surgeries for protocols as one phase/transmucosal healing or immediate loading. To help in the selection of the components, Neodent offers two aids, the CM height measurer and the CM Prosthetic Try in Kit. All items are manufactured in titanium and come in a cassette that can be sterilized and visualized in the Xrays. The following characteristics must be considered: a. Single or multiple restoration; b. Screwretained or cemented restoration; c. Interocclusal space, height and width; d. Gingival height (transmucosal height); e. Biological width (distance from the component to the bone crest); f. If there is necessity of the implant angulation correction for the abutment or if there is parallelism between adjacent components. 56

57 CM Height Measurer allows the gingival height to be determined. Subcrestal implant positioning results in a certain amount of bone over the implant coronal area that could collide against components which go adapted over the implants. The Try in Kit helps in checking if all biological spaces are free, either with direct view during a surgery or through an x ray periapical exam in healed sites. Example of a negative situation where the component is collapsing against the bone crest Example of the right situation where the component is respecting the biological width of the periimplant soft tissue. 57

58 9.1 Temporary Abutment options Pro Peek CM can be used in processes of one or twostages,conventional or immediate loading and single tooth or multiple. It is indicated as a temporary abutment for establishing tooth emergence profile before the final abutment selection. Pro Peek can be used as cemented or screwed restoration as the screw can be accessed through the temporary crown as presented in the Figure below. Pro Peek CM can be used as screwed or cemented restorations. 58

59 10. NEODENT KITS The Neodent kits come in a cassette for organization and sterilization of the instruments. The cassette is made of a shockproof thermoplastic polymer, which is suitable for frequent sterilization in the autoclave Sterilization The Neodent kits should be sterilized the day before or on the day of the procedure. The recommended is to follow the parameters for autoclave sterilization established by the norm BS EN ISO : Sterilization of health care products. Moist heat. Requirements for the development, validation and routine control of a sterilization process for medical devices. Do not sterilize in dry heat, since the cassette will be damaged. Validity for sterilization: 7 to 15 days, if stored in a clean dry environment, away from sunlight Cleaning and care of instruments The Neodent kits and instruments should be cleaned thoroughly after each procedure. Do not leave the instruments in a humid environment for long periods, since they may oxidize. Step 1 Separate and disassemble the instruments (if this is the indication) Step 2 Emerge completely in an enzymatic detergent solution (10%15%) Step 3 Wash cycle in an ultrasonic washer for 10 minutes Step 4 Flush in distilled water to completely remove any residues, with the aid of brushes. Step 5 Dry thoroughly with paper towels and/or compressed air Step 6 Inspect the instruments to certify that the cleaning process has been effective Step 7 Select the adequate packaging for the sterilization phase. Important: do not leave or store the instruments if they are not completely dry, so as to avoid oxidation. Do not use desincrustation solutions (nonenzymatic), since they may darken and oxidize the instruments. The use of enzymatic detergent solutions over 10%, and the inadequate removal of the solution during the cleaning procedure may also favor oxidation. 59

60 BIBLIOGRAPHIC REFERENCES (1) Brånemark PI, Hansson BO, Adell R, Breine U, Lindström J, Hallén O et al Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10year period. Scand J Plast Reconstr Surg Suppl. 1977;16:1132. (2) Gaviria L, Salcido JP, Guda T, Ong JL. Current trends in dental implants. J Korean Assoc Oral Maxillofac Surg Apr;40(2):5060.; (3) Gupta A, Dhanraj M, Sivagami G.Status of surface treatment in endosseous implant: a literary overview. Indian J Dent Res JulSep;21(3):4338. (4) Lambert PM, Morris HF, Ochi S.Positive effect of surgical experience with implants on secondstage implant survival.j Oral Maxillofac Surg Dec;55(12 Suppl 5):128. (5) Bernardes SR, da Gloria Chiarello de Mattos M, Hobkirk J, Ribeiro RF.Loss of preload in screwed implant joints as a function of time and tightening/untightening sequences.int J Oral Maxillofac Implants Jan Feb;29(1):8996. (6) Coppedê AR et al. Fracture resistance of the implantabutment connection in implants with internal hex and internal conical connections under oblique compressive loading: an in vitro study. Int J Prosthodont MayJun;22(3):2836. (7) Lazzara RJ & Porter SS. Platform switching: A new concept in implant dentistry for controlling abutment restorative crestal bone levels. Int J Periodontics Restorative Dent 2006;26:917. (8) Martin C, Thomé G, Melo AC, Fontão FN. Periimplant bone response following immediate implants placed in the esthetic zone and with immediate provisionalizationa case series study. Oral Maxillofac Surg 2015 Jun;19(2): (9) Barros RR, Novaes AB Jr, Muglia VA, Lezzi G, Piattelli A.Influence of interimplant distances and placement depth on periimplant bone remodeling of adjacent and immediately loaded Morse cone connection implants: a histomorphometric study in dogs Clin Oral Implants Res. 2010;21(4):3718. (10) Castro DS, Araujo MA, Benfatti CA, Araujo Cdos R, Piattelli A, Perrotti V, et al. Comparative histological and histomorphometrical evaluation of marginal bone resorption around external hexagon and Morse cone implants: an experimental study in dogs. Implant Dent 2014;23(3):2706. (11) Novaes AB Jr, Barros RR, Muglia VA, Borges GJ.Influence of interimplant distances and placement depth on papilla formation and crestal resorption: a clinical and radiographic study in dogs. J Oral Implantol 2009;35(1):1827. (12) Siqueira RAC. Avaliação do índice de sucesso e comportamento dos tecidos periimplantares de implantes cone morse equicrestais ou subcrestais em arcos inferiores.[master s dissertation on internet]. [Curitiba(Brazil)]: ILAPEO; [cited 28 out 2015] 126p. Available from: (13) SottoMaior BS, Lima Cde A, Senna PM, Camargos Gde V, Del Bel Cury AA. Biomechanical evaluation of subcrestal dental implants with different bone anchorages. Braz Oral Res 2014;28. (14) dos Anjos CM, Harari ND, Reis RSA, Vidigal Junior GM. Análise in vitro da infiltração bacteriana na interface de pilares protéticos e implantes conemorse / In vitro analysis of bacterial leakage at the interface between Morse taper implant platform and prosthetic abutments. ImplantNews;8(2):239243,

61 (15) Sartoretto SC, Alves AT, Resende RF, CalasansMaia J, Granjeiro JM, CalasansMaia MD. Early osseointegration driven by the surface chemistry and wettability of dental implants. J Appl Oral Sci May Jun;23(3):27987.; (16) Rupp F, Scheideler L, Eichler M, GeisGerstorfer J. Wetting behavior of dental implants. Int J Oral Maxillofac Implants NovDec; 26(6): (17) da Silveira BM. Análises tomográfica, microtomográfica e histológica entre enxertos em bloco autógeno e xenógeno nas reconstruções ósseas de maxila. [master s dissertation on internet].[curitiba(brazil)]: ILAPEO; [cited 15 jun 2014] 133p. Available from: html; (18) Mendonça G, Mendonça BD, Oliveira SL, Araujo AC. Efeitos da diferenciação de célulastronco mesenquimais humanas sobre superfícies de implantes hidrofílicas. ImplantNews 2013 NovDez 10(6a): (19) Glauser R, Portmann M, Ruhstaller P. Initial implant stability using different implant designs and surgical techniques. Appl Osseointeg Res. 2001;2(1):68. (20) da Cunha HA, Francischone CE, Filho HN, de Oliveira RC. A comparison between cutting torque and resonance frequency in the assessment of primary stability and final torque capacity of standard and TiUnite singletooth implants under immediate loading. Int J Oral Maxillofac Implants JulAug;19(4):

62