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Protetic 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 clinico-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 scopul de a deveni o infrastructur protetic

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Materiale din care se confecioneaz implantele:


Titanul i aliajele de titan Hidroxiapatita Safirbioceramica Zirconiu

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

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Clasificarea implantelor dup modalitatea aplicrii

ntr-un singur timp chirurgical


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n doi timpi chirurgicali

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Clasificarea implantelor dup form


Implante rdcin (root-form implants) Implante lam Implante ac Implante disc Implante combinate lam-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 (4-6 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 anti-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 (vizibilitatea coleretei metalice) 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 tisular a implantelor

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Integrarea osoas a implantelor


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

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Integrarea osoas pe termen lung

Biocompatibilitatea materialului Designul implantului Suprafaa implantului 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 ncrcare

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 Plan de tratament Tratamentul propriu-zis Dispensarizare

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Examinare
Stare general de sntate Examen loco-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, tulb. psihice severe,graviditate, pacieni nemotivai

Locale: factori anatomici, bruxism, raporturi ocluzale nefavorabile

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Radiografia panoramic
Examenul de baz ,indispensabil n implantologie Nu permite aprecierea precis a calitii osului spongios 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 unidentare-ed unidentar Puni cu agregare mixt ed terminal Puni cu agregare pur implantara- ed terminal Puni de ntindere mrit cu agregare mixt-bre ed lung Puni de ntindere mrit cu agregare implantarbre ed lung Proteza fix hibrid ( proteza high water, proteza Toronto) ed totale Punte total pe implante- ed totale Puni totale telescopate- 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 implantaraed 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 mixt-bre ed lung

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Puni de ntindere mrit cu agregare implantar-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- ed totale

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Puni totale telescopate- ed totale

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Tratament preprotetic chirurgical


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

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Grefe onlay

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ROG

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Distracie 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 : M-D, V-O Trebuie s fie rigid i transparent Trebuie s permit reflectarea lamboului muco-periostal

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Faza I 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 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-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 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 DTI-analogi se repun n amprent

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Amprenta cu DTI
Avantaje Se poate verifica la vedere repoziionarea ansamblului DTIanalogi DTI rmn pe cmpul protetic ca la amprentarea clasic Dezavantaje Exist dificulti la repoziionarea ansamblului DTIanalogi 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 o gaur de 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

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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. Obinerea unui model funcional mai fidel Se poate aplica i n cazul divergenelor implantare Dezavantaje Posibilitatea de deformare a amprentei la montarea analogilor Greu de realizat 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 2-3 cape (DTD) S fie vizibil jonciunea 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: osul se remodeleaz n funcie de forele aplicate asupra lui Riscul maxim de eec al implantelor este n primul an 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 lucrrii 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 1-2 sapt 6 sapt 6 luni 12 luni 24 luni 36 luni Anual RX 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 montrii SI dat.: -alterrii filetului intern al implantului -incongruenei 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 5

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