9/13 - Clinical Implant Provisionals, Implant Provisional Lab, Custom Tray Fabrication Flashcards
are implant provisionals implant-borne or tissue borne
implant borne
what are materials used for implant provisionals
- plastic of titanium temporary/provisional abutment
- acrylic (Jet or Trim)
- Bis-acryle (integrity)
- composite
- denture tooth
advantages of implant provisionals
- fixed
- tissue support
- identify implant and/or angulation problems
disadvantages of implant provisionals
- esthetic challenges (immediate/early)
- no removal during healing (immediate/early)
- implant vulnerability (immediate/early)
- no functional contribution (immediate/early)
- increased cost
what teeth do we provisionalize at creighton
anteriors
what are implant provisionals intended for
- post-surgical healing
- soft tissue development
- patient management
- predict prosthetic form/contour
- identify implant angulation problems
- evaluate questionable implants
when are implant provisionalization protocols IMMEDIATE
implants placed in function within 1 week of placement
when are implant provisionalization protocols EARLY
implant in function between 1 week and 2 months after placement
when are implant provisionalization protocols CONVENTIONAL/DELAYED
implant in function after 2 months healing
what situations are immediate implant provisionals used
in situations when:
- adequate primary stability
- no centric, eccentric, or protrusive contacts
- esethetic gain outweights risks associated w/ immediage loading protocols
- patient compliance w/ protocols
what is it called when the initial fixation of implant is sufficiently strong to withstand disloding forces
primary stability
what are examples of how primary stability is mechanical in nature
- osteotomy
- bone density
- implant geometry
- thread pattern
when is primary stability a MUST
in cases of immediate loading
as primary stability decreases, what happens to cumulative and secondary stability?
cumulative stability slightly decreases then maintains plateau
secondary stability increases
at creighton, when are implants considered progressive or delayed
after osteointegration
at what weeks is the implant most vulnerable to forces and must be avoid removal of provisional
2-4 weeks (15-21 days)
what can we do to test if implant is stable
- insertion/removal torque values
- periotest
- resonance frequence analysis (RFA) expressed as ISQ
what does RFA stand for
resonance frequency analysis
does denser bone have lower or higher insertion torque values
HIGHER
how does periotest work
a probe w/ accelerometer is placed on implant and calculates the contact time between the implant and probe
what does periotest correlate to
- micromovement
- variability
- lack of standardized values
what does RFA measure
interfacial integrity between implant and bone
what does RFA correlate with
implant bone contact and is expressed as ISQ
what does ISQ range from? what is the acceptable range? meaning what?
range from 1-100, acceptable is 55-85 meaning it has osseointegrated
what test provides variable results and interpretation of values
RFA
when are we unable to do implant provisional
- lack of primary stability
- parafunctional habits
- unable to eliminate centric/eccentric/protrusive contacts
- non-compliant patient
- non-esthetic zone
- esthetic gain does not outweigh risk of implant complications
when is prosthesis attached due to conventional loading
2 months post-implant placement (wait until implant osseointegrated)
when is conventional loading used
- sinus/ridge augmentation required
- compromised primary stability
- occlusal forces/parafunction
advantages of conventional loading
- ossointegrated implant
- tissue sculpting
- esthetics
- functional loading
disadvantages of conventional loading
- removable interim provisional
- lack tissue support during healing
can you add and subtract material on provisional to sculpt tissue
YES
what is the goal of soft tissue development
gingival symmetry with adjacent teeth
what is OPTIMAL corono-apical position of implant
3-4 mm apical to proposed CEJ
what corono-apical position of the implant is difficult to clean and manage deep sulcus?
> 5 mm apical to proposed CEJ
what corono-apical position of implant is unesthetic and results in short crown?
<3 mm apical to proposed CEJ
if you don’t have the option to do the optimal corono-apical position of implant and must choose between >5 mm or 3< mm, what should you choose?
better to do DEEPER (>5mm) than shallower
what does blanching of soft tissue mean
soft tissue has too much pressure
if tissue is constantly blanched, what is at risk
tissue necrosis
after provisional insertion, how long should you wait to see if blanching goes away? what do you do if it does not come back after this time period?
rub for 5 minutes - if pink doesn’t come back, provisional needs to be repositioned
what is evident around implant due to a highly polished provisional and appropriate emergence?
healthy tissue and hemidesmosomes
which teeth are higher of the anteriors?
central and canines are a “step” higher than laterals
how long does it take for tissue to mature
1-4 months
what is injected around soft tissue cast to insure an accurate soft tissue profile
PVS
can you place composite around PVS on soft tissue cast?
yes
when creating pick-up impression/open tray impression, what stays on impression?
coping stays on impression
are custom abutments custom made to patient
YES
what is the main advantage of custom abutments
control of margin position
how are you able to control margin position in custom abutments
- avoid sub-gingival margins
- prevent residual cement
- optimize abutment design
what do you do on day of implant surgery
- deliver essix retainer
- index implants for provisional implant crown fabrication
- confirm shade
- complete records (note)
how long do you wait between implant surgery and index before 2nd stage surgery/implant provisionals
4-6 months
what implant piece is used to create impression
open-tray impression coping
do you tighten open-tray impression coping with your hex drive or finger first?
finger first THEN drive
how should impression PVS be placed around open-tray impression coping?
coping must be covered circumferentially and two teeth indexed on both sides
what PVS is used for open-tray impression?why
clone bite or “O-bite” due to its greater rigidity and accuracy
should you loosen the guide pin before removing the index
YES
should you keep unscrewing the guide/survey pin until they become two separate pieces?
NO
if you do not have an index, can you make an impression at the time of second stage and fabricate the provisional thereafter?
yes
what implant piece do you place onto the open tray impression coping with the PVS
implant replica
what should you used to widen the area on the stone cast so your impression coping fits thru
8 acrylic round bur
when impression coping is placed thru stone model, what should you cover with it?
fast set plaster
what do you place in the facial aspect of the stone? why
a hole/window to allowed for material injection
where do you place base plate wax on impression/stone?
around junction of impression coping and implant replica
what do you used to load and placeplaster
monoject syringe
do you inject plaster thru the facial or bottom of the cast? what should you make sure you do
thru facial - make sure everything stays stable with no movement of index
when must you adjust the cylinder on the implant?
if matrix does not seat
what do you place inside the access channel?
gauze/cotton and rope wax
what can be placed over metal to prevent dark show thru of metal
opacifier (if PMMA is thin)
where do you add inlay wax? why?
add to gingival embrasure area to allow removal of provisional without breaking adjacent teeth
where to place coe-sep
stone and not cylinder
what can be placed around putty matrix and stone model with JET to prevent disloding when placing in warm water
rubber bands
do you open an access thru the jet material with round bur? do you remove the cotton and provisional?
yes, yes
do you add monomer or polymer to PMMA first
monomer
where should you not spill on provisional cylinder?
on internal fit
you should adjust contacts to prevent wrap around contacts. what should you not touch
contact area (incisal third)
do you hand tighten or use hex drive to connect provisional to stone
hand tighten
whenever placing a new abutment or healing screw, you should always irrigate implant fixture with what? why?
chlorhexidine using monoject syringe
this flushes saliva and bacteria out prior to seating abutment (high speed evac to remove excess)
when placing the provisional into the patient, what should you use to fill the access chamber?
dental tape - cut excess so short 2-3 mm of cingulum or central fossa
how much space is needed in provisional to place composite
2-3 mm
do you need bonding agent when placing composite into provisional
NO! mechanical fit will keep it in place
what are the materials that can be used for access hold filling?
- plumber’s tape/teflow + composite
- gutta percha + composite
- PVS material
- cotton pellets + composite
why dont we usually use guta percha for access hole filling
because difficult to remove
what dont we usually use PVS material for access hole filling
dark
why don’t we usually use cotton pellets for access hole filling
pellets absorb saliva and become smelly over time
implants provisionals must be what?
- esthetic
- smooth
- contoured appropriately to shape tissue
- used to communicate w/ lab
- temporary (finite lifespan to materials)
how many thicknesses of baseplate wax over TEETH for custom tray
2 thicknesses
how many thickness of baseplate wac over IMPLANT SITES for custom tray
3 thickness
what do you place between baseplate wax and triad
foil
where can handle be placed on custom tray for implants
- away from anterior implant site (need access to open tray impression coping pin)
OR
- on palate
triad curing time for custom tray
intiial 2 min on stone
cure another 2 minute without wax and foil
