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Slide 1

2003 By Default!

Protetic
Prote
tic fix pe implante

Catedra de protetic dentar fix i ocluzologie 2005 sef de lucrri Dr. Sergiu Drafta

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Obiectivele cursului

Implantologie generaliti
Clasificarea implantelor
Elementele sistemului implantar
Indicatiile implantelor
Limitele anatomice ale pozitionarii implantelor
Integrarea tisulara a implantelor
Etapele clinicoclinico-tehnice de realizare a RPF pe
implante

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Definiie :
Implantele

endoosoase sunt materiale


aloplastice care se inser chirurgical
ntr--o creast osoas rezidual cu
ntr
scopul de a deveni o infrastructur
protetic

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Materiale din care se


confecioneaz implantele:
Titanul i aliajele de titan
Hidroxiapatita
p
Safirbioceramica
Zirconiu

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Clasificarea implantelor
Dup raportul cu osul :endoosoase,
juxtaosoase (subperiostale, submucoase)
Dup momentul aplicrii :imediate, imediat
imediat-tardive,, tardive
Dup modalitatea aplicrii : ntrntr-un timp
chirurgical , n doi timpi chirurgicali
Dup form

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Clasificarea implantelor dup modalitatea


aplicrii

ntr-un singur timp


chirurgical

n doi timpi chirurgicali

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Clasificarea implantelor dup


form
Implante rdcin (root
(root--form implants)
Implante lam
Implante ac
Implante disc
Implante combinate lamlam-rdcin
Implante transmandibulare
Implante transfixante

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Implante rdcin

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Implante lam

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Indicaiile implantelor lam

Creste edentate nguste (4(4-6 mm.)


Proximitatea canalului mandibular
Proximitatea sinusului maxilar

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Implante cu alte forme

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Implantul transmandibular

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Implante transfixante

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Elementele sistemului implantar

Corpul implantar
urub de acoperire
Extensie permucozal
Stlpul implantar
DTI,DTD
Capa
Implantul analog
Surubul de fixare

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Alctuirea stlpilor implantari

Baza
Capul
Colereta

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Baza stlpilor implantari depinde


de dispozitivul antianti-rotaional al
implantului

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Modalitatea de fixare la corpul


implantar

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Capul stlpului implantar

Drepi
Angulai

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Colereta stlpului implantar

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Stlpi implantari estetici

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Criterii pentru alegerea stlpilor


implantari
Angulaia corpului implantar
Adncimea anului gingival
Estetica
E t ti (vizibilitatea
( i ibilit t coleretei
l t i metalice)
t li )
Nevoia de dispozitiv antirotaional
Accesul pentru igien
Nevoia de a realiza restauraii demontabile

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Indicaiile implantelor
Edentaia total
Edentaie parial terminal
Brea edentat lung
Edentaia unidentar

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Edentaia total

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Edentaia terminal

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Agregarea mixt

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Brea edentat lung

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edentatia unidentara

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Limitele anatomice ale poziionrii implantelor

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Limitele anatomice ale poziionrii


implantelor

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Integrarea
Inte
grarea tisular a implantelor

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Integrarea osoas
osoas a implantelor

A fost descris
descris de
Branemark
Absena esutului
conjunctiv de la nivelul
interfeei os
os--implant
este cheia succesului
clinic n implantologia
endoosoas.

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Integrarea osoas pe termen lung

Biocompatibilitatea
materialului
Designul implantului
Suprafaa
S
f iimplantului
l t l i
Statusul patului osos
Tehnica chirurgical
Condiiile de ncrcare

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Biocompatibilitatea

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Biocompatibilitatea

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Designul implantului

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Designul implantului

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Designul implantului
Implante rdcin conice
Implante cu hexagon intern
Implant i stlp implantar = o singur pies
(Direct NobelBioCare)
Implante lam nchise

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Suprafaa implantului
Plasm de titan
Gravaj acid
Sablare cu particule de siliciu sau cu oxid de
aluminiu
Tratament cu laser
Combinaii ale acestor metode

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Suprafaa implantului

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Plasma de titan

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Statusul patului osos

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Diagnosticul ofertei osoase

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Densitatea osoas

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Tehnica chirurgical

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fiziodispenser

Ser fiziologic rcit la 4 grade C


Piese cu reducie 20:1, 32:1

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Condiiile de nc
Condi
nc
rcare

ncrcarea gradual tardiv are cea mai


mare rat de succes i este recomandat
nceptorilor

ncrcarea imediat este rezervat cazurilor


n care stabilitatea iniial primara a
implantelor este excelenta (mai mare de 20
N:cm2)

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Reabilitarea oral cu lucrri


protetice fixe pe implante
Examinare
Diagnostic
g
Plan de tratament
Tratamentul propriupropriu-zis
Dispensarizare

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Examinare
Stare general de sntate
Examen locoloco-regional (dini naturali restani,
creste alveolare edentate, parodoniu,
ocluzia,, estetica))
Examinare paraclinic (radiografia
panoramic, teleradiografia de profil,
tomografia computerizat, modele de studiu,
machete diagnostice)

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Contraindicaii

Generale : diabet zaharat decompensat,


lupus, leucemii,hemofilie, TM regionale, boli
metastatice, abuz de alcool sau tutun,
tratament prelungit cu imunosupresoare,
ttulb.
lb psihice
ihi severe,graviditate,
idit t pacieni
i i
nemotivai

Locale:: factori anatomici, bruxism, raporturi


Locale
ocluzale nefavorabile

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Radiografia panoramic
Examenul de baz ,indispensabil n
implantologie
Nu permite aprecierea precis a calitii
osului spongios
p g
Mrirea dimensiunilor n plan vertical de
aproximativ 1,3 ori
Se folosesc abloane radiologice cu bile
metalice cu diametru cunoscut

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www.niznick.com
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Elaborarea planului de tratament


Alegerea tipului si numrului implantelor
Lucrri demontabile vs.cimentate
Agregare pur implantar vs.agregare mixt
Alegerea schemei ocluzale i a materialelor
ocluzale

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Opiuni terapeutice

Proteze mobilizabile
Puni colate
Puni convenionale
Restaurri pe implante

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Opiuni protetice n implantologie

Restaurri protetice fixe unidentareunidentare-ed unidentar


Puni cu agregare mixt ed terminal
Puni cu agregare pur implantaraimplantara- ed terminal
Puni de ntindere mrit cu agregare mixt
mixt--bre
ed lung
Puni de ntindere mrit cu agregare implantar
implantar-bre ed lung
Proteza fix hibrid ( proteza high water, proteza
Toronto) ed totale
Punte total pe implanteimplante- ed totale
Puni totale telescopatetelescopate- ed totale

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Coroan solo pe implant fixat prin


cimentare

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Coroan solo pe implant fixat prin


nurubare

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Puni cu agregare mixt ed


terminal

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Puni cu agregare pur implantaraimplantaraed terminal

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Tomato on stick

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Fixare din lateral

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Puni de ntindere mrit cu


agregare mixtmixt-bre ed lung

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Puni de ntindere mrit cu


agregare implantarimplantar-bre ed lung

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Proteza fix hibrid ( proteza high


water, proteza Toronto) ed totale

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Fixare din lateral

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Punte total pe implante


implante-- ed totale

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Puni totale telescopatetelescopate- ed totale

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Tratament preprotetic chirurgical


Grefe osoase tip onlay sau sandwich
ROG
Distracie osoas
Elevarea sinusului maxilar
Repozi
Repoziionarea nervului alveolar inferior

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Grefe onlay

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ROG

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Distracie osoas
Distrac
osoas

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Elevarea sinusului maxilar

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Repoziionarea NAI

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Tratamentul preprotetic: realizarea


ablonului chirurgical

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comar

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ablonul chirurgical

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ablonul chirurgical

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ablonul chirurgical

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ablonul chirurgical

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ablonul chirurgical

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ablonul chirurgical
Dicteaz plasarea implantelor n poziia cea
mai bun pentru suport, estetic,igienizare
Limiteaz chirurgul n timpul plasrii
implantelor
p
:M
M--D,, VV-O
Trebuie s fie rigid i transparent
Trebuie s permit reflectarea lamboului
muco--periostal
muco

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Faza I chirurgical
chirurgical : inserarea
implantelor

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Inserarea implantelor

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Faza a doua chirurgical

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Cape de vindecare sau stlpi


implantari definitivi?

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Alegerea stlpilor implantari i


montarea lor

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Amprenta

La nivelul corpilor implantari sau la nivelul


stlpilor implantari

Cu DTI sau DTD

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La nivelul corpilor implantari sau la


nivelul stlpilor implantari ?

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Amprenta la nivelul corpilor


implantari

Dezavuat de coala
Dezavuat
romneasc de
implantologie
Se folosete cnd se
utilizeaz stlpi implantari
UCLA
Se folosete cnd stlpii
implantari se selecteaz n
laborator
Este indicat n zonele n
care exigenele fizionomice
sunt maxime
Pe model analogii
corpurilor implantare

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Amprenta la nivelul stlpilor


implantari
Este necesar control radiologic pentru
evaluarea jonciunii corp implantar - stlp
implantar
Nu mai este necesar demontarea stlpilor
implantari ceea ce ar putea produce o rupere
a inelului conjunctiv periimplantar
Este indicat atunci cnd stlpii implantari au
fost alei i fixai definitiv n timpul fazei a II
II--a
chirurgicale
Pe model analogii stlpilor implantari

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Amprenta cu DTI sau DTD?

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Amprenta cu DTI
DTI
Sunt confecionate din
metal sau plastic
Rmn pe cmpul
protetic la ndeprtarea
p
p
amprentei din cavitatea
bucal
Au feele laterele uor
conice i uneori au
poriuni plane pentru a
ajuta poziionarea lor n
amprent
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Etapele amprentei cu DTI

Se nurubeaz DTI la corpii sau la stlpii implantari


Se alege i se probeaz o lingur standard care s
corespund nlimii DTI
Se aplic adeziv pe lingur
Se prepar materialul de amprent, se ncarc
lingura si se introduce n cavitatea bucal a
pacientului
Dup priz, se ndeprteaz amprenta din c.b.
Se dezinfecteaz amprenta
Se deurubeaz DTI i se nurubeaz n stlpii
sau corpii implantari analogi
Ansamblul DTIDTI-analogi se repun n amprent

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Amprenta cu DTI
Avantaje
Se poate verifica la
vedere repoziionarea
ansamblului DTIDTIanalogi
DTI rmn pe cmpul
protetic ca la
amprentarea clasic

Dezavantaje
Exist dificulti la
repoziionarea
ansamblului DTIDTIanalogi
Exist posibilitatea
producerii deformrii
permanente la
dezinseria amprentei
Nu se aplic n cazul
existenei de
divergene implantare

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Amprenta cu DTD
DTD
Au o form
paralelipipedic
retentiv
Au
A o gaur
de
d acces
pentru uruburile de
fixare (tije ghid)
Tijele ghid au lungimi
de 10, 15, 20 mm.

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Etapele amprentrii cu DTD

Confecionarea unei linguri individuale deschise n


dreptul DTD
Se fixeaz DTD la implante sau la stlpii implantari
Se aplic adeziv pe lingur si pe DTD
Se prepar materialul de amprent, se ncarc
lingura si se introduce n cavitatea bucal a
pacientului
Dup priz , se deurubeaz tijele ghid ale DTD
care ns nu se scot din amprent
Se ndeprteaz amprenta din gura
Se dezinfecteaz amprenta
Se conecteaz la DTD analogii

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Confecionarea lingurii individuale


Confec

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Abutment
Analogues
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Amprenta cu DTD
Avantaje
Risc sczut de
deformare a amprentei
la ndeprtarea din c.b.
Obi
Obinerea unuii model
d l
funcional mai fidel
Se poate aplica i n
cazul divergenelor
implantare

Dezavantaje
Posibilitatea de
deformare a amprentei
la montarea analogilor
Greu
G
de
d realizat
li t n
regiunile posterioare
ale arcadelor mai ales
n cazul unei
amplitudini mici a DM
cronofag

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Confecionarea modelului
funcional

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Confecionarea abloanelor de
ocluzie
Se pot folosi : -DTD
-cape sau cilindrii prefabricai
(metalici sau din plastic)
Pentru susinerea ablonului sunt necesare
minim
i i 2
2--3 cape (DTD)
S fie vizibil jonciunea cap(DTD)cap(DTD)-SI
Bordura de ocluzie e ntrerupt n dredtul
tijelor ghid

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Confecionarea abloanelor de
ocluzie

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nregistrarea de ocluzie

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Montarea modelelor n articulator

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Protezarea provizorie i ncrcarea


progresiv a osului
Legea lui Wolff:
Wolff: osul se remodeleaz n
funcie de forele aplicate asupra lui
Riscul maxim de eec al implantelor este n
primul an
p
Timpul de tratament pentru ncrcarea
progresiv a osului depinde de densitatea
osoas
Dac exist o cretere rezonabil a
solicitrilor , densitatea osoas
periimplantar poate crete

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Confecionarea scheletului metalic


al suprastructurii

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Proba scheletului metalic al


suprastructurii n cavitatea bucal
Testul Sheffield (verificarea pasivitii)
Dac lucrarea nu e pasiv:
-se secioneaz scheletul metalic
-se solidarizeaz intraoral cu Duralay
-se face o cheie vestibular de gips sau siliconi
-se scoate scheletul metalic si cheia vestibular din gura
pacientului
-se plaseaz stlpii analogi
-se toarn modelul
-se ndeprteaz rina i se repoziioneaz scheletul metalic
pe model
-se aplic cear la locul de lipire
-se ambaleaz n vederea lipirii
-se lipeste

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Testul Sheffield

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Proba scheletului metalic al


suprastructurii n cavitatea bucal

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Aplicarea placajelor fizionomice

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Proba i adaptarea lucr


lucrrii
rii
protetice definitive ; fixarea
temporar

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Fixarea definitiv

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Igienizarea
Regimul de ntreinere personal
permanent
ntrit periodic prin dispensarizare
Procedurile de igienizare:
-de 3 ori pe zi
-perii de dini medium i soft
-perii de dini interproximale
-nururi dentare i panglici dentare
-periue dentare electrice
-aparatul WATER PIK
-ape de gur de 2X pe zi

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Control clinic i radiologic


control

RX

1-2 sapt
6 sapt
6 luni
12 luni
24 luni
36 luni
Anual

da
da
da
da
La fiecare 3
ani

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Criterii de succes Albrektsson 1991


Absena mobilitii
Absena durerii
Absena infeciei periimplantare
Absena sngerrii la palpare
Pierdere osoas 1.0-1.5mm n primul an;
apoi < 0.1mm anual
Rata de succes la 5 ani 95% iar la 10 ani de
85%

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Complicaii

Complicaii imediate

Complicaii tardive

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Complicaii imediate
Accidente la montarea SI pe corpul implantar
Imposibilitatea mont
montrii SI dat.:
-alterrii filetului intern al implantului
-incongruenei SI
SI--corp implantar
-fracturrii prii filetate a SI
-mobilitii corpului implantar prin lipsa stabilitii
primare
Accidente i greeli la montarea suprastructurii
protetice
-fractura urubului de fixare a lucrrii protetice
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Complicaii tardive
Complicaii ale esutului moale:
Gingivita proliferativ
Expunerea filetului corpului implantar
Igienizare necorespunztoare
Complicaii osoase
Pierderea progresiv a osului marginal
Mobilizarea corpului implantar
Complicaii mecanice
Fractura corpului implantar
Slabirea SI sau a uruburilor de fixare
Fractura urubului SI
Fractura suprastructurii protetice

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Ocluzia RPF pe implante

Dup obinerea integrrii tisulare primare a


implantelor cauza principal a pierderii
iniiale de os din jurul implantelor este
prezena unor fore ocluzale excesive

Lipsa ligamentului parodontal determin


pierderea influenei lui protectoare,
neexistnd mecanisme specifice de aprare
mpotriva forelor ocluzale

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ncrcarea axial a implantelor

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Ocluzia RPF pe implante

Ocluzia lingualizat poziionat medial

Legea componentei celei mai slabe

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Ocluzia lingualizat poziionat


medial

Implantele inserate,
att la mandibul, ct
i la maxilar realizeaz
o ocluzie mai medial
dect schema natural
ocluzal n care
cuspidul vestibular
mandibular este
cuspidul dominant

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Conceptul componentei celei mai


slabe

Cnd un segment al unor arcade este supus


unor factori de for mai mari sau are un risc
mai mare de complicaii dect segmentul
antagonist el reprezint o component mai
slab

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Realizarea unei inocluzii


verticale de 30 de microni la
lucrrile agregate pe implante

Zarb, Chapman

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Cazul 1

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Cazul 2

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Caz 3

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Caz 4

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Caz 9

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Caz 10

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