DENTIUM-practical Course Training - Sylabus

IMPLANT INTENSIVE
PRACTICAL COURSE
CONTENTS
01. What is Implant?
02. Implant Types
03. Dentium Implants
04. Anatomy
05. Patient Evaluation
06. Implant Selection
06. Treatment Plan
07. Case Presentation

What is Implant?
An Implant is a medical device manufactured to replace a missing

biological structure, support a damaged biological structure, or enhance
an existing biological structure.
A dental implant is a "root" device, usually made of titanium, used in

dentistry to support restorations that resemble a tooth or group of teeth
to replace missing teeth.
Dental implants can be used to support a number of dental prostheses,

including crowns, implant-supported bridges or dentures. They can also
be used as anchorage for orthodontic tooth movement.
History of Dental Implant
Ancient - Egypt, Middle East, Honduras, Maya civilization
- tooth shaped shell or Ivory
1728 - Pierre Fauchard : Metal Screw post Implant
1809 - Maggilio : Gold Implant
Modern Implantology
1941 - Dahl : Subperiosteal Implant

1947 - Formiggini : Tantalum twisted Spiral Endosteal Implant
1963 - Linkow : Tantalum Vent - Plant,
1967 - Linkow blade
1965 - Branemark Implant System :
History: As a Vital microscopic technique to study healing events and Microcirulation in

bones and bone marrow using rabbits fibula, titanium chambers containing an optical
System for transillumination was implanted for the study. The optical chambers used
could not be removed because the titanium framework became completely incorporated
in bone.
Thus, the concept of OSSEOINTEGRATION emerged.
The first Branemark implant was placed in human jaw in 1965.
Osseointegration
OSSEOINTEGRATION is defined as a direct structural
and functional connection between ordered, living bone
and the surface of a load-carrying implant.
(Branemark 1985)
OSSEOINTEGRATION is a process hereby clinically

asymptomatic rigid fixation of alloplastic materials is
achieved, and maintained, in bone during functional load.
(Zarb & Albrektson 1991)
5
Implant Types
Classifications
By Connection:
- External vs Internal
By Surgical position:
- Submerged vs Non-Submerged
By Surface Characteristics:
- Smooth vs Rough Surface vs Chemical Modification
By Body Design:
- One body implant (Solid) vs Two body implant (hollow)
- Parallel body vs Tapered Body
Others - Zirconia Implants

Connection
External Internal
- ABUTMENT CONNECTED EXTERNALLY - ABUTMENT CONNECTED INTERNALLY

- SCREW LOOSENING - PREVENT SCREW LOOSENING
- MULTI IMPLANT CASE - MORE LOADING STRENGTH
7
Surgical position
GBR? STABILITY? CONVENIENT?

POSITION? COSMETIC?
Submerged Non-Submerged
ONE BODY VS TWO BODY
ONE BODY TWO BODY
VS
Surface Characteristic
Smooth Surface
- Machined surface
Rough surface
- Sand blasted with Large grit and Acid
etching (SLA),
- resorbable blast media (RBM),
- Etching,
- Sintering
Chemical modification
- HA Coating,
- Oxidised
Implant Surfaces
Machined surface
eg. Branemark Implant Sand blasted with Large
grit and Acid etching
eg. Dentium, Straumann HA coating
eg. Steri-oss
Oxidized Surface
Anodizing
eg Nobel Direct
eg. Nobel Biocare
Sintering
Ti-Unite
eg. Endopore
SLA - the standard of rough surface
growth factor
BMP
collagen
peptide coating
DENTIUM - SUPERLINE
SUPERLINE
Easy Esthetics
Beautiful Teeth.
Superior esthetic biomaterials and
individualized applications.
Soft Tissue Integration

Beautiful Gingiva.
Surfaces, designs, and procedures for maintaining
and regaining natural soft tissue.
Immediate Function
No healing time required prior to functioning.
Surfaces, designs, and procedures for maintaining
implant stability.
Focal
contact
The effects of Implant surface topography on the behavior of

cells
Surgically created wound Immediately condition the surface.
during implant installation Expose material surface to wound
fluid & molecules; rich in fibrin,
fibronectin, hyaluronic acid
Enhancing adsorption of circulating

growth factors & cytokines and
promoting cell migration
DENTIUM - SIMPLELINE
Increase overall stability
1.Implant surface texture

2.Implant surface treatment
3.Implant fixture design
Initial stability
Initial stability
almost like a cylindrical, press-fit implant

Design - tapered implant;
SuperLine
Higher initial stabilization

- early loading
Reduced bone heating

- easy drilling sequence
- easy installation
FX3610SW FX4010SW FX4510SW FX5010SW FX6010SW FX7010SW

Fixture Design Features
Superline
Taper portion
Double threads
Bone expansion & Initial
Smooth and tight fixation
stability
Parallel portion
S.L.A. Surface S.L.A.
Distribute stress evenly
Successful early loading
F
23
Taper portion Biological Thread

Rich bone housing design
Easy Installation
Insertion Torque Curve - Superline
Superline,
attractive implant system for
hard & soft tissue integration
Taper neck design give a strong primary stability
Attractive Implant System
for clinician
- Minimize GBR procedure
- No bone resorption due to even stress distribution
- Easy and well achievement of initial stability
- Faster Osseointegration
- Easy prosthetic procedures
- Reasonable Price
- Company Support & Service
Our patients want !
Short treatment time Few
injection Good esthetics Short
term provisional Reasonable Fee
Marginal Bone Stability
It is a key factor
for a way
to esthetic outcome
Bone response 1. conventional loading 0.35mm bone

Marginal bone remodeling loss after 1 year
Stable marginal bone 2. early loading 0.55mm bone loss after
1 year and after that the bone level was
maintained
Conical Seal Design
11
*Self guiding f2
allows simple assembling
*Tight relation f1 F
eliminates micro-motion,
less screw loosening
*Geometric locking
creates strength, rigid connection
*Conus surface
distributes load evenly
Platform switching
- Cell: withdrawal tendency

- from connecting point (joint)
between fixture and abutment
- Biological width concept
- Horizontal offset: most important factor
- Inflammatory cell infiltration:
away from the bone
Effect of platform switching
(Lazzara 2006)
Typical bone loss Platform switching

(saucerization) (>0.4mm)
Platform switching:
A new concept in implant dentistry for controlling
postoperative crestal bone level
(RJ Lazzara & SS Porter IJPRD 2006)
Once exposed in the oral cavity following the
implant installation,
the coronal bones are remodeled.
ANATOMY
ANATOMY
A inferior alveolar nerve
B dentogingival nerve
C mental nerve
D incisor nerve ( anterior
inferior alveolar nerve )
A mental nerve
B dentogingival nerve
C incisor nerve ( anterior
inferior alveolar nerve )
ANATOMY
A posterior superior alveolar nerve
B anterior superior alveolar nerve
C infraorbital nerve
D lateral nasal nerve
A posterior superior alveolar nerve

B middle superior alveolar nerve
C anterior superior alveolar nerve
D dental plexus
E canine plexus
F infraorbital nerve
Systematic
Evaluation
Absolute contraindications
Relative contraindications
Others
Absolute Contraindications
Systemic diseases Cancer and AIDS
Cardiac diseases
Deficient haemostatic and blood dyscrasias
-Hemophilia, Thrombocytopenia, Acute leukemia,
Agranulocytosis.
Anti-coagulant medication -Aspirin, Wafarin
Psychological disease
Uncontrolled acute infection
Drugs used to treat or prevent postmenopausal
and steroid-induced osteoporosis.
Pregnancy
Relative Contraindications
Diabetes
Jaw irradiation
Chemotherapy
Smoking
Others
Osteoporosis
Age
Dental
Evaluation
General Considerations
Dental Examination
for Implant Therapy
General Considerations
Radiographic examinations
-Panorama, Full mouth series
Since they serve as the reservoir of bacterial

colonization, the infected periodontal site and
caries must be addressed prior to surgery
Good oral hygiene is critical in implant treatment;

as for the cooperation of the patient
Dental Examination
for Implant Surgery
Arch shapes and Sizes
-Required for deciding the number and positions of implant
especially among edentulous patients.
Maximum intercuspation,
Centric relation and Occlusal interferences
-In case of partially edentulous patients, the existing
occlusion can be maintained or must be considered prior to
surgery in case improvement is necessary
Anterior guide
-In the absence of an anterior guide, implants in the
posterior may receive excessive lateral force.
-Excessive anterior guide may result in overload on the
implants in the anterior.
General wear facets and Other signs of parafunctional habits
-Implant prosthesis should be protected from other hazardous forces.
Interarch relationship
-Posterior Implants require about 7mm of space, and the anterior,
8~10 mm. In the case of implant-retained removable prosthesis, at least
12 mm space is required for the bar clip.
Adjacent teeth
-Single implants need at least 7 mm of space from the CEJ of the
mesial tooth to that of the distal tooth.
-The mesial inclination of the distal tooth must be addressed either
prosthetically or orthodontically.
-Adjacent teeth should not be exposed to infection sources;
otherwise, periodontal or endodontic treatment must be performed first.
Aesthetic evaluation
-The analysis of the smile line is essential in an implant treatment in
the upper anterior.
Diagnostic casts & Diagnostic wax-up

Clinical
Evaluation
Evaluation of tissue health

Attached gingiva
Evaluation of the edentulous space
Palpation
Evaluation of tissue Health
Edentulous gingival tissue should neither be inflamed nor
afflicted with pathogens.
Attached gingiva
Edentulous gingival tissue should neither be inflamed nor
afflicted with pathogens.
The volume of the attached gingiva should be measured

at MGJ.
Although the sufficient volume of the attached gingiva is

not necessarily required, it is important for the long-term
maintenance of prosthesis.
Evaluation of the edentulous space
The buccolingual ridge should at least be 6mm wide.
The mesiodistal ridge should be at least 7 mm wide.
Knife-edge ridge
-Bone grafting and FGG may be necessary.
-The ridge split technique can be applied.
Palpation
Palpate a ridge to check the existence of concavity or
exostosis.
In case of the lower posterior, check the concavity in the
lingual side, and in the upper anterior, that in the labial
side.
Radiographic
Diagnosis
Periapical Radiographs
Panoramic Radiographs
Lateral Cephalogram
Transparent sheets for implant selectio
C.T & Cone Beam
Periapical Radiographs
Distortion is minimised using the parallel technique.
The bone level of adjacent teeth must be visible.
The use of the grid enables direct length measurement.
Its main application is recall check.
Panoramic Radiographs
Bone quality, quantity and anatomical limitation may
be evaluated.
Distortion often occurs and varies by image.
The application of radiographic template using
radiopaque markers is recommended.
Lateral Cephalogram
During implant installation, the surgeon can check the
thickness of the cortical bones as well as the volume of
the buccolingual bones in the lower anterior or symphysis
grafting is required.
Transparent sheets for Implant Selection

Select an implant using the transparent sheet provided by
Choose the implant size and length with appropriate

proportions by calculating the augmentation ratio.
C.T & Cone Beam
Best accurate radiology for implant installation.
Choice of implant length, diameter
and position
Implant length
Implant diameter
Implant position
Implant length
Determine the implant length based on bone
availability and calculate the available bone
height.
For implants in the lower posterior, perform
osteotomy with at least 2mm space away from
nerves.
Choosing a relatively long implant is
unnecessary given sufficient bone height.
A longer implant does not provide additional
support, instead making surgical cooling trickier.
Implant diameter
Measure the buccolingual ridge dimension. Set the
diameter with more than 1 mm of buccal and lingual bone
remain. If the ridge is narrow, expand with osteotome or
perform GBR and ridge splitting.
For the mesiodistal area, maintain 3mm distance between
implants and set the diameter such that there is at least
1.5mm distance between the implant and natural teeth.
Indications for small diameter ( 3.4) Implant
-Reduced inter-root space: The inter-root distance is less than 7mm.
-Thin alveolar crest
-Reduced mesio-distal prosthetic space
Indications for large diameter ( 4.3, 4.8) Implant
-Insufficient bone quality
Implant diameter
In case of posterior teeth, let the implant angulation tend
toward the center of the occlusal surface and face the
functional cusp of antagonist teeth.
In case of anterior teeth and cemented prosthesis, place
the implant along the axis toward the incisal edge.
If insertion into the ideal position is difficult, use a phased
approach through bone grafting prior to insertion.
Avoid damaging the adjacent teeth of the implant.
Maintain at least 1.5mm space between the implant and
adjacent teeth (PDL space of adjacent teeth + 1mm).
In case of multiple implants, maintain at least 3mm of
space among implants and place them parallel to each
other if possible.
TreatmentPlan
ning
Reference : Australian Dental Journal Volume 53, Suppl 1, June 2008

General considerations
Treatment planning must include the prosthesis design, grafting
procedures, temporization, and number and positions of
implants.
A detailed plan should be prepared for surgery and prosthesis.
If more complicated procedures such as bone grafting and
multiple implant installations are involved, treatment documents,
order, and treatment schedule and duration as well as any and
all changes should be documented.
Initial disease control should precede treatment planning.
Initial disease control phase
- Treatment of periodontal & endodontic problems
- Caries control
- Oral hygiene instructions
- Extraction of hopeless teeth
- Transitional restoration
Prior to treatment planning, it is important to motivate the
patients and evaluate their estimated long-term cooperation
based on their reaction to early Tx.
Selecting a Prosthetic Design
General principles
Prosthesis types
- Fixed
- Removable restoration
Prosthetic options depend on the conditions of
partial and fully edentulous patients.
Diagnostic casts and wax-up are necessary for purposes
of prosthetic design selection and explanation to the
patients.
General decision criteria
Comfort level of the dentist & technician
Patient access to maintenance
Feasibility of repairs
Research-based design when available
Patient expectations
Other general considerations
a. Connection vs. No connection to natural teeth
Although avoiding the connection between natural teeth and
implants is recommended, it is not a contraindication in some
carefully chosen cases.
For teeth with insufficient periodontal support, however, avoid such
connection.
If connection is necessary, perform final cementation on rigid fixed
prosthesis to prevent the intrusion of natural teeth.
b. Cantilever vs. No cantilever

If possible, avoid cantilever restoration (may cause overload on the
implants).
Cantilever should be limited to a short span.
For edentulous cases and fixed prosthesis, treatment can be made
with the distal cantilever whose length is up to 1.5 times as large as
distance between the center of the foremost implant and that of the
rearmost implant.
By installing implants inclined distally in the most posterior area, the
amount of cantilever can be reduced.
If arranging the implants in the appropriate positions is difficult,
consider the removable prosthesis as an option.
c. Inter-and Intra-arch space
At the stage of treatment planning, consider in advance the

inter- and intra-arch space and height and width of the
prosthesis to be inserted.
Before selecting the prosthesis, check the heights of all
prosthetic components.
Ex) Removable prosthesis
-Height of the implant abutment
-Height of attachment and housing
Forming the appropriate occlusal plane requires
reducing the height of antagonist teeth.
Secure the appropriate inter-proximal distance for
prosthetic and orthodontic purposes.
Excessive inter-arch space may result in poor
crown/implant ratio.
d. One-stage vs. Two-stage Implant
Whether to perform one-stage or two-stage implant installation
depends on the condition of the patient as determined by the
surgeon.
Advantages of One stage surgery
- Sufficient soft tissue healing time.
- Stabilization of JE & Sulcus depth.
- No disruption of mature peri-Implant tissue during prosthetic work.
Disadvantages of One stage surgery.
- Infection during bone healing phase.
- Previous enough bone grafting (Staged approaches).
- No chance of healing time after surgical trauma.
Two-stage Implant : SUPERLINE
- Designed for two-stage implant installation, SUPERLINE widens the
abutment for an implant with narrow diameter for enhanced emergence
profile.
In other words, the emergence profile in the existing SUPERLINE is
not affected by the implant diameter.
- Indication: SUPERLINE can be used when the bone width is not ideal
and in case the gingiva is too narrow or thick.
Standard Implant surgery protocol : Two stage surgery.

- Conservative & Safe.
- Less bone loss due to enough healing time before 2nd stage
surgery.
Guideline for one or two staged approaches.

- Good patient cooperation.
- No infection source.
- No smoking.
- More delicate drilling.
- Enough antibiotic & antiseptic coverage: 1week antibiotics, 2
weeks chlorhexidine, after 2weeks, tooth brushing one stage surgical
approaches area.
Treatment Planning
in the esthetic zone
General considerations
Aesthetic evaluation must be performed, and possible
limitations, identified.
During Tx planning, a plan for a temporary prosthesis that

ensures the patients comfort and satisfaction must be
prepared.
In case of insufficient soft tissue and/or hard tissue, perform

grafting to install implants in more ideal positions and fabricate
aesthetic prostheses.
Diagnosis
First, examine the smile line of the patient.
Photographs of the oral cavity can help visualize the basic points more
specifically.
Check whether the incisal edges are natural along the inferior line.
Evaluate the amount of gingiva exposed.
Determine the causes of gummy smile.
- Malpositioned maxilla Orthodontic evaluation is necessary.
- Short lip (Lip incompetence at rest but normal maxilla)
- Hyperactive upper lip (Normal lip coverage at rest, but uncovering
during smile)
- Excess soft tissue
If the smile line is unaesthetic, various Tx options should be offered to
patients.
In the aesthetic zone, installing implants in more accurate positions is
critical. Otherwise, hard and/or soft tissue grafting should be performed as
supplementary treatment.
Once installed, the implant restricts other treatments. In particular,
some orthodontic tooth movements require the extraction of implants.
Treatment Planning
The emergence profile of the prosthesis should be

considered carefully.
To secure a natural emergence profile, implants should be
inserted more deeply in the posterior area.
A surgical stent is a prerequisite to ideal implant
positioning in the aesthetic zone.
Although an inaccurately inserted implant toward the
labiolingual side can be corrected with an angled abutment,
the correctable angle is limited.
The future resorption of bone and soft tissue must be
considered. Therefore, grafting should be performed slightly
excessively.
Biotypes & Difficulties
of Restoration
a. Thick & Flat biotype
Most common
Teeth are square with relatively parallel roots
Contact point is wide
Underlying bone is thick and resistant
Papilla are flat and wide
Generally associated with favorable surgical and restorative outcomes
b.Thin & Scalloped biotype
Comprises 20% of the population
Teeth have conical roots and triangular crowns.
Underlying bone is thin, and dehiscences are frequent.
Papilla extend incisally, becoming thin and delicate.
When a tooth is missing, severe hard and soft tissue loss has
occurred.
Surgical reconstructions are difficult, particularly when
attempting to regenerate papilla.
A favorable outcome is more difficult to achieve, and
expectations should be tempered.
Number of missing teeth
a. One missing tooth

Teeth adjacent to the edentulous space have a significant
effect on the maintenance of tissue height.
The papilla is well maintained given good bone support for
adjacent teeth.
b. Two or more missing teeth
Severe loss of hard and soft tissue requires advanced surgical
procedures.
Inter-implant bone must be well maintained to support the
proximal tissues.
Secure at least 3mm space between implants.
Insufficient space between implants results in the loss of inter-proximal
bones due to the early remodeling, flattening of the gingiva, and loss of
papilla.
Timing of Implant treatment
Traditional treatment sequences
courses are the most widely accepted and acknowledged.
The most ideal waiting period for implant installation is 8
weeks after the extraction.
Whereas restoration needed to be performed 3~6 months
after implant installation, the period has been shortened to
6~12 weeks with the development of the implant surface.
For the second-stage surgery, a waiting period of at least 6
weeks is required.
Assuming good conditions, however, one-stage surgery is possible.

Surgical Stent / Guide
Principle
A surgical stent is an acrylic appliance used to
ensure the ideal installation of an implant.
A surgical stent serves to assure accurate
implant positions according to diagnosis and
treatment planning.
In some cases, however, insufficient bones
make ideal positioning impossible. Therefore,
remember that the stent itself does not
guarantee perfect positioning.
Sufficient irrigation and appropriate
accessibility are prerequisites.
Interim prosthesis options
a. No provisional replacement
1 or 2 teeth are missing in the posterior area.
The patient retains his/her masticatory functions, and if it is in
non- aesthetic zone.
b. Provisional removable appliance
The existing partial denture of the patient, if any, can be used
To avoid applying prosthetic pressure on the inserted implants, refrain
from using prosthesis for the first 2~3 weeks after the surgery.
Even after such time, be careful not to apply excessive force on the implants
with a proper relief.
When performing bone grafting, a pressure-free state must be
maintained during the waiting period. In this case, some changes are required
for the removable appliances such as the shortening of the flange.
Retainer-like provisional restoration in the anterior area merely resolves some
aesthetic problems; it does not have actual functions.
If the surgery site requires protection, install artificial teeth after taking an
impression and fabricate a stent using vacum former.
Provisional Denture Stent with single tooth
,
Provisional fixed prosthesis
In case of good-quality bones like those in the lower
anterior, acryl fixed provisional prosthesis can be loaded right
after the insertion. Although this is the ideal method since no
pressure is applied on the insertion sites, its use should be
limited.
Personal oral hygiene and professional maintenance care are
necessary.
Other Solutions
Bonded bridge : Artificial or extracted tooth bonded to
adjacent teeth can replace removable appliances, although
removal and repositioning are trickier.
Small-diameter temporary implant
- Partial edentulism: Make a fixed provisional prosthesis by
inserting temporary implants around the final ones.
- Full edentulism: Provide the implants with support from the
denture to avoid applying pressure on the insertion site.
Additional considerations
For the healing period, provisional restoration should be
adjusted and relined.
Advise patients on how to maintain oral hygiene as well

as on the proper ways of using dentures.
Remember that maintaining oral hygiene in case of

healing abutment and temporary prosthesis is the
first step toward the better maintenance of the final
restoration.
Case
Presentation
Case Study 1
1 2
3
Case Study 2 3
1
2
Case Study 3
2
Case Study 4
3
1
2
Case Study 5
3
2
4
Case Study 6
1
2
Case Study 7
1
2
Case Study 8
1
2
Case Study 9
1
3
2
4
Case Study 10
2
3
IMPLANT INTENSIVE
PRACTICAL COURSE
CONTENTS
01. Implant Surgical Procedure
02. Block bone hand-on
03. Implant Surgical Procedure
04. Implant Placement Hand-on
05. Post-operation
IMPLANT SURGERY PROCEDURE
Pre-op
Local Anaesthesia
Surgery set-up
Incision
Drilling
Fixture placement
Suture
Post-op
PRE-OPERATION
CHX mouth rinse (about 1min)
Prophylactic antibiotics: Some evidence of
reduced early failure of dental implants due
to infection ( A.D.Pye et al. 2009)
Patient Management
- Talk about Procedure
- Sign Consents Form
ANAESTHESIA
: ENOUGH INJECTION
LIGNOSPANARTICA
INEINFILTRATIONBL
OCK
SEDATION
- BEFORE SURGERY SET UP

- PREFER TO USE ANOTHER ROOM FOR
PRE-OP & ANAESTHESIA
SURGERY SET UP
Infection Control !!
Infection Control
INFECTION CONTROL !!
Infection Control
SURGICAL INSTRUMENTS !!
SURGICAL MOTOR SURGICAL
KIT & IMPLANT BONE GRAFT
MATERIALS
INSTRUMENTS
RETRACT INCISION SUTURE
MINESOTA #12,#15BLADE NEEDLE HOLDER

CHEEK BLADE HOLDER SCISSORS
PERIOSTEAL TISSUE FORCEP
- MOLT #9
- P24G
- BUSER
SELDIN
CURETTE
97
RETRACT
MINESOTA
CHEEK
PERIOSTEAL
- MOLT #9
- P24G
- BUSER
SELDIN
CURETTE
98
INCISION
#12 , #15
BLADE
BLADE
HOLDER
SUTURE
TISSUE FORCEP
NEEDLE
HOLDER
SCISSORS
SURGICAL MOTOR
CHECK BEFORE START
SPARE HAND-PIECE
BODY FOOT
PEDAL TUBING
SALINE TUBING
HAND-PIECE
CHECK
FUNCTION
OPTIC
REAL TORQUE
SURGICAL SET
UP
SURGICAL SET
UP
103
Surgical Kit and
Implants
104
BONE GRAFT MATERIAL
BONE &
MEMBRANE

INCISION
MidcrestalLingual /
Palatal BeveledH-
incisionContinuousPa
pilla intactPapilla
depressed
Continuous Incision
108
Papilla intact
When the interdental papillae are in an

acceptable position, papilla-saving incisions
are made to minimize soft tissue reflection.
The incisions are vertical to allow primary
closure. When the papillae are depressed,
the vertical release incisions include the
papilla in the edentulous site.
109
Papilla depressed
In situations with a more depressed soft

tissue, facial soft tissue and papillae over
each adjacent tooth are also reflected. The
crestal incision is on the palatal incline on
the ridge.
110
DRILLING CHECK POINT
PLATFORMDRILLING
LOCATIONBONE
DENSITYDRILLING ANGLE AND
DEPTHDRILLING SEQUENCES
PLATFORM
CURRETAGEROUND
BURPERIODONTAL ELEVATOR
DRILLING LOCATION
Adjacent to natural
toothAdjacent to
implantBounded saddleFree-end
saddleBuccolingual(Buccopalatal
) Guide pin to verify
relation to opposing
and adjacent teeth
: Functional cuspe
Adjacent to natural tooth
Consider available restorative space, bone and
proximal root positions
2mm to prevent food trap
< 1.5mm, risk of bone resorption
Consider opposing functional cusp!
Consider final prosthesis!
* The maxillary canine root is
often slanted 11 degrees distally A maxillary first
and has a distal curvature 32% premolar implant
of the time. When the implant is may need to be
placed parallel to the first parallel to the
premolar, it may inadvertently canine.
encroach upon the canine root.
When the implant is placed : When the implant is placed:
Long fixture installation (X) Shorter and bigger
fixture installation (O)
When the implant is placed
: Long type fixture installation (X)

117
118
119
120
121
Adjacent to Implant
Minimum 3mm between implants

<3mm: high risk of crestal bone resorption
Consider opposing functional cusp
Consider final prosthesis
1.5~2mm 3~4mm 1.5~2mm

123
124
125
126
127
Bounded saddle
Single: in the middle

Multiple: careful calculation
Initial drilling point: 4~5mm from natural tooth,
7~8mm between implant drilling points
Consider opposing functional cusp
Consider final prosthesis
1.5mm 3mm 1.5mm 1.5mm 3mm 3mm 1.5mm

FREE END SADDLE
Consider available restorative space, bone and

proximal root positions
2mm to prevent food trap
< 1.5mm, risk of bone resorption
Minimum 3mm between implants
Consider opposing functional cusp!
Consider final prosthesis!
139
BUCCOLINGUAL
Minimum 1mm vital bone on buccal and
lingual(palatal) surfaces
2mm to prevent gingival recession
ex. For 6mm ridge width, 4mm or narrower
implants
GBR, Ridge splitting or Ridge expansion
Beware of buccal fossa
Too close to buccal
154
155
156
BONE DENSITY classification
D1 - Anterior Mandible
Dense and wide cortical bone.
D2 - Posterior Mandible
Anterior Maxilla
Dense-to-porous cortical bone on the crest and
within the bone, and coarse trabecular bone
D3 - Posterior Maxilla
Thinner porous cortical crest and fine trabecular
bone
D4 - Posterior Maxilla
No or thin crestal cortical bone.
The fine trabecular bone composes most of the
total volume of bone.
D1 D2 D3 D4
BONE BLOCK HAND ON
DRILLING ANGLE
perpendicular to occlusal
surface Parallel to adjacent
teethBisecting angle
160
161
Paralleling pin insertion
: Verification of parallelism of implants
and relation to adjacent & opposing teeth
169
170
Initial drilling point is
imperative in lower 1st,2nd molar especially
-Not to locate too distally!
-Not too upright
2010.03.08 Pre-op
2010.03.09 Post-op
DRILLING DEPTH
SLIGHT OVER
PREPARATIONBEWARE OF
ANATOMICAL FEATURES: IAN,
SINUS, REAL
ETCLENGTH OF DRILL ?
X-RAY RATIO? NERVE? SINUS?
WHERE AM I?
182
Surgical Procedure
Fixture Installation
D1 ~ D2
(I)
( II )
D3 ~ D4
Wide Fixture Installation
Same apex size

: 5.0 and 6.0 implat
Mount Free
SURGICAL PROCEDURE
: SUPERLINE
INCISION
Lindemann Guide Drill
(1,200rpm)
5mm
SuperLine
4010 Fixture
[D.-4.0, L.-10mm]
(1,200rpm)
SuperLine Implantium
4010 Fixture 3810 Fixture
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
(1,000rpm)
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
Lindemann First Drill
(1,000rpm)
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
(1,000rpm)
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
(1,000rpm)
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
(1,000rpm)
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
3.6 Final Drill
(1,000rpm)
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
3.6 Final Drill
(1,000rpm)
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
4.0 Final Drill
(1,000rpm)
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
4.0 Final Drill
(1,000rpm)
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
4.0 Countersink (1,000rpm)
* When bone is dense, drill down to the top laser mark
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
Fixture [D.-4.0, L.-10mm] Installation
* During insertion, 35N.cm at 20rpm is recommended
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
(0.5mm below the bone crest)
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
Fixture [D.-4.0, L.-10mm] Installation with Ratchet
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
Fixture [D.-4.0, L.-10mm] Installation with Ratchet
(Avoid over-torque of more than 70Ncm)
0.5mm
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
(1,000rpm)
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
(1,000rpm)
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
(1,000rpm)
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
(1,000rpm)
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
3.6 Final Drill
(1,000rpm)
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
3.6 Final Drill
(1,000rpm)
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
4.0 Final Drill
(1,000rpm)
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
4.0 Final Drill
(1,000rpm)
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
* During insertion, 35N.cm at 20rpm is recommended
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
Non-Submerged Protocol
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
Suture
Submerged Protocol
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
Submerged Protocol
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
Submerged Protocol
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
Submerged Protocol
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
Submerged Protocol
[D.-4.0, L.-10mm] [D.-4.0, L.-10mm]
Submerged Protocol
Suture
SURGICAL PROCEDURE
: SIMPLELINE
SimpleLine II
SOFX654310R
SimpleLine II
SOFX654310R
SimpleLine II
SOFX654310R
slim one body
clinical cases
Healing Abutment vs
Cover Screw
Healing Abutment - moderate or good bone

- insertion torque above 15Ncm
- no need for second surgery
Cover Screw - poor bone quality

- insertion torque less that 15Ncm
- smoker, poor OH, diabetes, etc
- temporary removable denture
- if any doubt
SUTURING
provide adequate tension for wound closure,

but loose enough to prevent tissue ischemia
and necrosis
maintain hemostasis
permit healing by primary intention
reduce postoperative pain
prevent bone exposure resulting in delayed
healing and bone resorption
permit proper flap position 256
Suture
Non-resorbable:
Silk, Polyester (Nylon, PTFE)
Resorbable:
Natural (Plain gut, Chromic
gut),
Synthetic (Coated Vicryl)
SUTURING TECHNIQUES
SIMPLE INTERRUPT
HORIZONTAL
VERTICAL
CONTINUOUS
CONTINUOUS INTERRUPT
8 FIGURE
CROSS
SLING 258
Simple Interrupted Suture
259
Figure 8 Modification
260
HAND-ON
DRILLING
IMPLANT PLACEMENT
SUTURE
261
262
Thats it for today folks!

IMPLANT INTENSIVE
PRACTICAL COURSE
CONTENTS
01.Follow up
02.Temporary Prosthesis
03.Second Surgery
04.Intraoperative Complications
05.Failure
06.Loading Time
POST-OP INSTRUCTION
GUAZE PLACEMENT
MEDICATION - ANALGESIC, ANTIBIOTIC, CHX
ICE PACK
265
Wound healing mechanism
contraction
epitheliazation
connective tissue deposition
266
4 stages of healing
hemostasis
inflammation (2-5 days)
proliferation (2 days- 3 weeks)
remodeling
267
post-op gingivival recession
initial recession attributed to

inflammation (1 week)
most of recession occurs during
first 3 months
definitive impressions should not
be made after 3 months of healing
in aesthetic areas
268
Soft tissue
Parallel collagen fibers

Impaired defense due to less vascular supply
(Berglundh et al.)
Fibroblast-rich layer is important for sealing
(Moonet al.)
Gold layered abutment-controversial
Longer epithelium and connective tissue when
269
implants are placed 1mm deeper (Todescan et al.)
270
FOLLOW UP
IN 1-2 WEEKS
CHECK WOUND HEALING
CHECK ANY LOSS OF SENSATION
CHECK ANY SIGNS OF INFECTION
SUTURE REMOVAL
WOUND DRESSING
TEMPORARY PROSTHESIS
TEMPORARY ABUTMENT
TEMPORARY REMOVABLE DENTURE
TEMPORARY BRIDGE (Splinting)
NO TEMPORARY RESTORATION
SECOND SURGERY
PUNCH or BUR
INCISION
HEALING ABUTMENT SELECTION
(SIZE, HEIGHT)
- Depend on Emergency profile
- 1mm bigger than implant nomally
AT LEAST 2 WEEKS BEFORE
IMPRESSION
Gingival Punch
274
275
INCISION
Buccal flap resorption
INCISION
: Pedicle formation
a) Incision b) Cover screw removal
c) Healing abut. Connection & d) Suture

Pedicle formation
Intra-operative complications
Haemorrhage
Neurosensory impairment
Dehiscence and fenestration of implants
Perforation of sinus or nasal cavity
Damage to adjacent teeth
Failure to obtain primary stability
Fracture of implants or instruments
Foreign bodies or pathological lesion
Emphysema in the head and neck region
Aspiration and swallowing of instruments
Haemorrhage
Diffuse Bleeding: Sponge bone- stops

spontaneously
Moderate Bleeding: Endosseous implant bed-
stops by insertion of implant
Severe bleeding: Posterior mandibular
implant bed- clarify the situation using X-ray
and depth gauge
Anticoagulants
Ecchymosis
282
Neurosensory impairment
To protect the IAN and Mental N

: precise location of IAN canal with pre-op. X-rays
Intraoperative X-rays with a drill placed
To protect the Lingual nerve: thin periosteal
insertion into the lingual surface, minimal lingual
mucoperiosteal flap
Be a Chicken when you are
dealing with IAN!
284
Dehiscence and fenestration of implants
Repositioning and
GBR necessary
285
Perforation of sinus or nasal cavity
Predetermining radiographic assessment

Patients sinus status
Damage to adjacent teeth
high frequency in single tooth saddle

preoperative evaluation
RCT, Orthodontic correction

Beware where you
are going to!
Failure to obtain primary stability
: Check bone Density!!!
When you drilling!!!
Drilling modification
larger size implants
Osteotome / Bone expander
remove any implants with mobility
Fracture of implants or instruments
incorrect handling
too many sterilisation cycles
overheating
immediate removal of all the fragment in the
least traumatic fashion
291
Foreign bodies
root fragmentsroot canal filling

materialsfractured endodontic instrumentsno
abscess or soft tissue allowedAny foreign
body NOT allowed in the implant field before
the surgery
Emphysema in the head and neck region
Turbine hand-piece is
contraindicatedSymptoms: sudden swelling,
palpable crepitus in the soft tissueUsually
harmlessCold compressionProphylactic
antibiotic administration
Aspiration and swallowing of instruments
choking
chest X-ray
monitor
295
Immediate Implant
SimpleLine Surgical guide
Extraction
Atraumatic extraction
Lindemann Drill
800~1,200rpm / 30~45N.cm
Final Drill 3.4

800~1,200rpm / 30~45N.cm
Final Drill 3.8

800~1,200rpm / 30~45N.cm
Bone graft application

OSTEON : DT7G0510050
Palatal engagement
SimpleLine : SOFX483812R
Healing Abutment Connection

No Suture
Healing Abutment : HAB4820
Provisional Restoration
Dual Abutment Octa : SODAB4855
Impression coping;
Fixture Level
Impression Coping Transfer 4.8
: SODTF4852
Final prosthesis
Gingival Contouring with provisional restoration
Final prosthesis
Gingival Contouring with provisional restoration
Failure of dental implants
Early failure
- inability of tissue to establish osseointegration
Late failure
- failure to maintain osseointegration
Early Failure
minimal bone loss
lack of osseointegration
due to the absence of bone
apposition and the formation of
scar tissue at BIC
more common than late failure
Early Failure
: Iatrogenic causes
surgical trauma
(overheating, compression
necrosis)
bacterial contamination
premature overloading
Early Failure
: other causes
Age and Sex
Systemic Diseases
Smoking
Type of Edentulism
Location
Bone Quality and Quantity
Implant Length and Diameter
Immunological and Genetic factors
Age and Sex
in most studies, not related
more failure 40-60 yo than over 60
: older age not contraindicative
(Noguerol et al.)
Systemic Diseases
more failure in diabetes
Crohns disease and osteoporosis
chemotherapy and radiotherapy
gastric, cardio, controlled diabetes 1, asthma,
blood pressure, hyperthyroidism,
hypercholesterolemia, etc not BRONJ(bisphosphate
related (Alsaai et al.)
related osseonecrosis on

the jaw):
BRONJ Intravenous-contraincated
Oral-3yrs,
6mths cessation
AAOMS (American Association of Oral and

Maxillofacial surgeons)
Smoking
one in every three implant failures in smokers
heavy smokers, 12~21% failure
success rate of GBR 65% (95% in
nonsmokers) Garg 2010, Abt 2009, Cochran
et al. 2009, Lindfors et al. 2010
smoking alone cannot be considered as a risk
factor for early failure (Sverzut et al.)
recommendation: no smoking 1wk before and
8wks after surgery
Type of edentulism
increased failures of implants
placed adjacent to teeth
location
3 times more failure in the maxilla than the
mandible
half the early failure occur in the posterior
maxilla region (Steenberghe et al.)
more failures in the posterior than the anterior
mandible (Alsaadi et al.)
Bone Quality and Quantity
D3, D4 and limited quantity showed higher
failure (Steenberghe et al.)
Poor quality did not affect the percentage of
early failure. (Alsaadi et al.)
Implant Dimension
length and diameter has no significant effect
on early failure
Late Failure
Periimplantitis
Implant overloading
Malposition or overangulation of implants
Implant fracture
Loading Time
Immediate Loading
Early Loading
Delayed Loading
Conventional: 3~6 months
Stability Measurement (ISQ)
Percussion test
Impact Hammer Method (Periotest, Dental
mobility checker)
Pursed oscillation waveform
Resonance Frequency Analysis
(Osstell, Implomate)> 65 ISQ
Osstell(ISQ)
Thank you
333
IMPLANT INTENSIVE
PRACTICAL COURSE
CONTENTS
01.Prosthesis Part
02.Dentium Prosthetic System
03.Prosthesis Procedure
- Fixture Level Impression (Transfer Type)
- Fixture level Impression (Pick up Type)
- Abutment Level Impression
- Screw Abutment
04. Implant Over denture
- Ball Abutment
- Magnetic Abutment
- Positioner
05.Delivery of Superstructures
Prosthesis Part
Various type of
approach for loading
Two stage One stage Immediate restoration
(Cover screw submerged, (implant with perimucosal (restoration placed at the time
healing abutment, of the implant placement)
then uncovering surgery) no uncovering surgery)
Ti-customized abut. Zirconia-customized abut.
2 months after surgery
Provisional restoration in situ
Consideration for peri-implant esthetics
customized zirconia-titanium abutments
Final prosthesis in situ
6 month following prosthesis insertion
Cement Retained Restoration Screw Retained Restoration
Screw Abutment & Cylinder
Dual
Combi

Direct-Casting
Dual Milling
Angled (15 / 25)

USE same impression coping Temporary (Ti / Plastic)
SCRP is possible
SUPERLINE
CONNECT
IN THE
PATIENT
MOUTH
FOR TAKING
IMPRESSION
TAKE
IMPRESSION
WITH
IMPRESSION
COPING
Combi Abutment
- Combi Abutment is used in case the procedure goes desirably and is unnecessary to
take out the abutment.
- After Abutment is selected, Abutment Level Impression is taken.
- If the abutment selection is made in the mouth, gauge the thickness of mucosa with the
depth gauge to measure the gingival height thus allowing the appropriate abutment
height.
- Fixture Connection Part and Prosthetic Part are one piece.
- For recovery of single tooth, tighten abutment screw to 20~35Ncm (retighten again
before seating final prosthesis to prevent inaccurate impression of the rotating abutment)
Dual Abutment
-It is possible to taken an impression at both fixture level and abutment level.
(A dual abutment is compatible with a combi abutment)
- For fixture Level impressions,
the abutment selection takes place on the master model.
- For abutment level impressions,
the same prosthetic procedure apply to both dual and combi abutments.
- A precise positioning jig for abutment is required.
- Either Hex or Non-hex may be used, according to clinicians preference.
Dual Milling Abutment
- Identical to dual abutment in general.

- When gingival height is different, it is used for esthetic reason.
- When the path revision is required.
- When gingival level is deep and regular abutment is not
available.
- When occlusal site is large, it is easy to reduce quantity of the
gold.
Angled Abutment
- The angled abutment is recommended when the

restoration path of insertion mostly in anterior site is
unfavorable.
- 15/ 25type
Screw Abutment
-Easy to repair prosthesis due to the screw type abutment.

-Useful for connecting multiple units or if there is a
preference for a screw retained prosthesis.
- Useful when respective implant path differs. Each side
tapers by 30 degrees and this permits up to 60 degrees
divergence between two abutments.
- Useful if the prognosis of an adjacent restoration is not
ideal thus permitting easy retrieval and modification of the
restoration.
Direct-Casting Abutment
- Excellent for either single or bridge restoration.

- Used as an esthetic custom made abutment.
- Used when angulation is not ideal and a regular abutment cannot be used.
- Used when there is inadequate inter-arch distance and a standard abutment cannot be
used.
-A fixture level impression is taken, and the soft tissue contours can be supported.
Temporary Abutment
- The plastic abutment comes in diverse diameters (4.5,

5.5, 6.5) with a fixed gingival height of 3.0mm.
- Use it for immediate loading case.
- Temporary abutment are available in titanium or plastic
abutment.
Abutment
Selection
Prosthesis Procedure
1. Abutment level impression
(Combi abutment Multi units)
2. Fixture level impression

- Transfer Type
(Dual abutment Multi units)

- Pick up Type

- Transfer Type
(Dual milling abutment Multi units)

- Transfer Type
(Angled abutment Single unit)

- Transfer Type
(Direct casting abutment Single unit)
7. Screw abutment (SCRP)

- PFG / PFM prosthesis

- Zirconia prosthesis
9. Implant over-dentures
- Ball abutment

- Magnetic Abutment

- Positioner
SUPERLINE
4. Prosthesis Manual SuperLine & Implantium
SUPERLINE
Fixture level impression
- Transfer Type
Remove Cover screws
Remove Healing abutments
Insert Impression copings (transfer type) into Fixtures
Take Impression [closed tray]
Remove the Impression copings from oral cavity
and connect it with Analogs firmly
Insert the connected Impression copings and Analogs
into the impression
Pour the soft gum silicone and trim
Master cast
Master model
Measure gingival height with Depth gauge
Select abutments with proper diameter and gingival height
Positioning jig
Wax-up
Cut-back
Metal framework
Opaque
Porcelain build-up
Final prosthesis
[Tighten it to 25~30N.cm and Re-tighten after 15minutes]
- Pick up Type
Insert Impression copings (pick-up) into Fixtures
Take impression [open tray]
Unscrew Impression coping screws
before removing the impression tray
Master cast
Master model
Positioning jig
Wax-up
Cut-back
Metal framework
Opaque
Porcelain build-up
Final prosthesis
[Tighten it to 25~30N.cm then Re-tighten after 15 minutes]
Abutment level impression
Remove Cover screws
Select suitable Combi abutments, then torque down at 25~30N.cm
[Re-tighten after 15 minutes]
Connect Impression copings over the Abutment firmly
[Snap-on]
click
Fabricate provisional restorations, or use Comfort caps
Connect Lab analogs into Impression copings
[Match flat side of both analog & coping]
Master cast
Master model
Connect Burn-out cylinders
Wax-up
Cut-back
Metal framework
Opaque
Porcelain build-up
Final prosthesis
- Transfer Type
(Dual milling abutment

Multi units)
Select Dual milling abutments of proper diameter
Master model
Modification
Modification
Abutment after milling process
Positioning jig
Wax up
Cut-back
Metal framework
Opaque
Porcelain build-up
Final prosthesis
Clinical Case
2008.02.13
2008.05.13
2008.06.14
2008.12.05
Photo view
G.B.R.
2nd Surgery
Zirconia Coping
- Transfer Type
(Angled abutment Single

unit)
Remove Healing abutment
Fixture level impression coping connection Transfer type (Closed tray)
Fixture level impression taking Transfer type (Closed tray)
Master model
Fixture level / Master model making

Angled abutment hex type connection
Angled abutment modification
Positioning jig making
Wax-up
Cut-back
Completed metal framework 454
Porcelain build-up
Insertion of Custom abutment using positioning jig
[Tighten it to 25~30N.cm then Re-tighten after 15 minutes ]
Final prosthesis
Clinical
Case
09.09.18 pre-op
Key-point :
Selection of proper implant position
12ixx22i vs x11i21ix
1) Available bone quantity and

quality
2) Biomechanical consideration
3) Esthetic consideration
4) Technical consideration
- natural emergence profile
- abutment dimension &
space for substructure &
layering porcelain
09.09.18 post-op
Zirconia
Prosthesis
Final Setting
09.11.04 Final Setting

- Transfer Type
(Direct casting abutment

Single unit)
Fitting of Direct casting abutment
Modification Wax up
Completed custom abutment
Positioning jig
Wax-up
Cut-back
Completed gold framework
Opaque
Porcelain build-up
Final Prosthesis
Final Prosthesis
Clinical Case
Screw abutment (SCRP)
Screw abutments with delivery holder
Select and seat appropriate Screw abutments
with delivery holder
After insertion, tighten it with Ratchet adapter
[Tighten it to 25~30N.cm then Re-tighten after 15minutes]
Seat Impression copings on Screw abutments
Take impression (closed tray)
Seat comfort caps on the Screw abutments
Remove the impression copings from oral cavity
and connect it with analogs firmly
into the impression
Master cast
Master model
Gold-cylinders on the Screw abutment analogs
[Tighten it to 10N.cm with Ti-Retaining screw]
Consider the distance of opposing teeth,
modify cylinder to its proper height if needed
Wax-up
Cut-back
Opaque
Porcelain build-up
Final prosthesis
Select and insert appropriate Screw abutments
Take impression [closed tray]
+
into the impression
Master cast
Master model
Connect Titanium cylinders
Master model
Tray resin copping made
+
Tray resin framework buccal view
1.5~2.0mm
+
Tray resin framework occlusal view
Buccal : 1.0~1.5mm
Lingual : 0.5mm
Mock-up tray resin framework completed
+
Ready for mounting on a copy milling machine
+
Milled zirconia block completed
Rainbow substructure
+
Zirconia core
+
Porcelain build-up
Veneering Porcelain Rainbow substructure
+
Final Zirconia Prosthesis
[Tighten it to 10N.cm]
+
Clinical Case I
Screw Abutment Zirconia Prosthesis
2008.08.27 Pre-op
2008.09.03 Post-op
2008.11.26 Final prosthesis

Clinical Case II
Restoration of a failed bridge

with SuperLine system
09.07.18 pre-op
Key-point :
1. How to restore patients masticatory
function as early as possible.
2. Proper implant position and occlusal
design considering opposing dentition.
09.07.18 post-op
09.09.23 Final Prosthesis
Implant over-dentures
- Ball abutment
Ball abutments
Insert Ball abutments into fixtures
Cover the Comfort caps onto abutments
Take impression
Insert Analogs into the impression tray
[Impression coping embedded in impression tray]
After Analogs insertion
Fabricate denture in common method
Connect Female sockets with Analogs
Examine the interference between inner surface
of female sockets and Ball analogs
Apply the resin with a brush
into the denture inner surface
Position the denture into the model
and wait for initial setting
After resin setting, trim the resin excess
and polish the denture
- Magnetic Abutment
Insert Implant keepers into Fixtures
Seat Magnetic assay on the Implant keeper
Examine the interference
between denture and magnetics.
Relief of denture inner surface.
Examine the Interference
between denture and magnetics
Apply the resin on the relief area of denture.
Position the denture into the mouth.
After resin setting, polish the denture.
Clinical Case
2009.05.27 oral exam

Clinical Case
2009.09.04 Post-op
Clinical Case
2010.01.15 Magnetic connection

Overdenture - Magnetic Attachment
Recommendation
For Fixed Prosthesis
Transfer or Pick-Up type Impressions
Screw retained Restoration
For Removable Prosthesis (Over-dentures)
Ball Abutment or Positioner
Chairside Intra-Oral Application

Delivery of Superstructure
Superstructure = Abutment + Crown/Bridge/Fixed or Removable Prosthesis
1. Abutment Connection (for Fixture Level impression)
- using Transfer key or repositioning jig
2. Check Contact point(s)
3. Check the fitness of superstructure
- Passive fit ?
- Radiographic Assessment
- Adjust or Remake
4. Occlusal Adjustment
5. Cementation or Screw fixation or SCRP
- Temporary or Final cementation

Repositioning Jig
Contact Point
Fitness of Superstructure
before cementation
After cementation
Occlusal Design
Narrow Occlusal Table
Lateral Force
- Centric contact on Implant
- Flat cuspal inclination
- No Lateral contact
- Lateral guidance on Natural teeth
- Minimal 3 implants for lateral guidance
- Avoid Cantilever design

Connection Type
Screw-Retained Restoration
- Occlusal screw fixation
- Horizontal or transversal screw fixation
Cement-Retained Restoration
- Retrievability ???
SCRP (Screw and Cement Retained Prosthesis
Combination Type restoration

Restorative Materials to seal Screw Access Hole
Cotton Roll and/or Cavit
New Product from Dentium
Glass Ionomer Cement or Composite resin

Screw Retained Restoration
Occlusal Screw Fixation
Screw tightened to torque of 25N/30Ncm

Horizontal or transversal screw fixation
Cement Retained Restoration
Which Cement ?
Resin based Luting cement

e.g. Panavia F, NX3, Clearfil Aesthetic Luting cement, Multilink Automix
Resin Modified GIC

e.g. RelyX Unifast, G-cem, RelyX Luting Plus
GIC
e.g. Fuji IX, Ketac Cem
Cemented Retained Restoration
- It is used as a cementation repair method when:
* In case of screw loosening or if prosthesis repair is needed.
* Prosthesis separation from abutment due to cement loss
* Adding to the interproximal contact surface due to prosthesis loosening
- It provides passive insertion of prosthesis and enhance the adaptibility
A screw type restoration helps to simplify prosthesis repair, including insertion and removal
of the prosthesis if necessary.
Cement type restoration tend to have a stable occlusion and may enhance the adaptability.
However the weak point is that it cannot be removed after permanent cementation.
A dual abutment can be cemented or screw retained.
Combi abutments are cement retained and no occlusal hole is necessary.

- It is used when one implant is placed at different bone level compared to other ones.
- Cement-retained restoration for implant placed at ideal depth

- Screw retained restoration for implant placed at deeper than ideal.
Late Complication
1. Gingival recession
- Resorption of buccal bone wall,

- tension of labial frenum,
- incorrect brushing technique
Tx: Recommend the periodontal and plastic surgery
2. Loosening of the Implant
- Secondary loosening caused by Occlusal factor
Tx: Attention should be given to achieve the Optimised loading,

Regular occlusal adjustment every 3 years
3. Peri-implant Infection
- develop gradually ( Newman & Flemming 1988)

- there is a good chance to treat if any inflammatory changes can be detected
ASAP.
Tx: Patient motivation and good oral Hygiene,

Regular Recall
However, an analysis of the clinical trials of the ITI system reveals that a very small
proportion of failures seem to be associated with occlusal overload. From this analysis
the major cause of late failures could be attributed to peri-implant infections. It was
noted that patients with good oral hygiene tended to keep implants longer.
Australian Dental Journal 2003;48:(4):212-220
Current treatment options for peri-implant infections

1) Antibacterial treatment with systemic antibiotics
2) Rinse with 0.2% Chlorhexidine
3) Surgical corrections
If All failed Removal of Implant

Thank you for your Attention !!!
IMPLANT INTENSIVE
PRACTICAL COURSE
CONTENTS
01.Prosthesis Part
02.Dentium Prosthetic System
03.Prosthesis Procedure
- Fixture Level Impression (Transfer Type)
- Fixture level Impression (Pick up Type)
- Abutment Level Impression
- Screw Abutment
04. Implant Over denture
- Ball Abutment
- Magnetic Abutment
- Positioner
05.Delivery of Superstructures
Prosthesis Part
Various type of
approach for loading
Two stage One stage Immediate restoration
(Cover screw submerged, (implant with perimucosal (restoration placed at the time
healing abutment, of the implant placement)
then uncovering surgery) no uncovering surgery)
Ti-customized abut. Zirconia-customized abut.
2 months after surgery
Provisional restoration in situ
customized zirconia-titanium abutments
Final prosthesis in situ
Cement Retained Restoration Screw Retained Restoration
Screw Abutment & Cylinder
Dual
Combi

Direct-Casting
Dual Milling
Angled (15 / 25)

USE same impression coping Temporary (Ti / Plastic)
SCRP is possible
SUPERLINE
CONNECT
IN THE
PATIENT
MOUTH
FOR TAKING
IMPRESSION
TAKE
IMPRESSION
WITH
IMPRESSION
COPING
Combi Abutment
- Combi Abutment is used in case the procedure goes desirably and is unnecessary to
take out the abutment.
- After Abutment is selected, Abutment Level Impression is taken.
- If the abutment selection is made in the mouth, gauge the thickness of mucosa with the
depth gauge to measure the gingival height thus allowing the appropriate abutment
height.
- Fixture Connection Part and Prosthetic Part are one piece.
- For recovery of single tooth, tighten abutment screw to 20~35Ncm (retighten again
before seating final prosthesis to prevent inaccurate impression of the rotating abutment)
Dual Abutment
-It is possible to taken an impression at both fixture level and abutment level.
(A dual abutment is compatible with a combi abutment)
- For fixture Level impressions,
the abutment selection takes place on the master model.
- For abutment level impressions,
the same prosthetic procedure apply to both dual and combi abutments.
- A precise positioning jig for abutment is required.
- Either Hex or Non-hex may be used, according to clinicians preference.
Dual Milling Abutment
- Identical to dual abutment in general.

- When gingival height is different, it is used for esthetic reason.
- When the path revision is required.
- When gingival level is deep and regular abutment is not
available.
- When occlusal site is large, it is easy to reduce quantity of the
gold.
Angled Abutment
- The angled abutment is recommended when the

restoration path of insertion mostly in anterior site is
unfavorable.
- 15/ 25type
Screw Abutment
-Easy to repair prosthesis due to the screw type abutment.

-Useful for connecting multiple units or if there is a
preference for a screw retained prosthesis.
- Useful when respective implant path differs. Each side
tapers by 30 degrees and this permits up to 60 degrees
divergence between two abutments.
- Useful if the prognosis of an adjacent restoration is not
ideal thus permitting easy retrieval and modification of the
restoration.
Direct-Casting Abutment
- Excellent for either single or bridge restoration.

- Used as an esthetic custom made abutment.
- Used when angulation is not ideal and a regular abutment cannot be used.
- Used when there is inadequate inter-arch distance and a standard abutment cannot be
used.
-A fixture level impression is taken, and the soft tissue contours can be supported.
Temporary Abutment
- The plastic abutment comes in diverse diameters (4.5,

5.5, 6.5) with a fixed gingival height of 3.0mm.
- Use it for immediate loading case.
- Temporary abutment are available in titanium or plastic
abutment.
Abutment
Selection
Prosthesis Procedure
1. Abutment level impression

- Transfer Type

- Pick up Type

- Transfer Type
(Dual milling abutment Multi units)

- Transfer Type
(Angled abutment Single unit)

- Transfer Type
(Direct casting abutment Single unit)


- Ball abutment

- Magnetic Abutment

- Positioner
SUPERLINE
SUPERLINE
- Transfer Type
Remove Cover screws
Insert Impression copings (transfer type) into Fixtures
Remove the Impression copings from oral cavity
and connect it with Analogs firmly
into the impression
Master cast
Master model
Positioning jig
Wax-up
Cut-back
Metal framework
Opaque
Porcelain build-up
Final prosthesis
[Tighten it to 25~30N.cm and Re-tighten after 15minutes]
- Pick up Type
Insert Impression copings (pick-up) into Fixtures
Take impression [open tray]
Unscrew Impression coping screws
before removing the impression tray
Master cast
Master model
Positioning jig
Wax-up
Cut-back
Metal framework
Opaque
Porcelain build-up
Final prosthesis
Abutment level impression
Remove Cover screws
Select suitable Combi abutments, then torque down at 25~30N.cm
[Re-tighten after 15 minutes]
Connect Impression copings over the Abutment firmly
[Snap-on]
click
Fabricate provisional restorations, or use Comfort caps
Connect Lab analogs into Impression copings
[Match flat side of both analog & coping]
Master cast
Master model
Connect Burn-out cylinders
Wax-up
Cut-back
Metal framework
Opaque
Porcelain build-up
Final prosthesis
- Transfer Type
(Dual milling abutment

Multi units)
Select Dual milling abutments of proper diameter
Master model
Modification
Modification
Abutment after milling process
Positioning jig
Wax up
Cut-back
Metal framework
Opaque
Porcelain build-up
Final prosthesis
Clinical Case
2008.02.13
2008.05.13
2008.06.14
2008.12.05
Photo view
G.B.R.
2nd Surgery
Zirconia Coping
- Transfer Type
(Angled abutment Single

unit)
Remove Healing abutment
Fixture level impression coping connection Transfer type (Closed tray)
Master model
Fixture level / Master model making

Angled abutment hex type connection
Positioning jig making
Wax-up
Cut-back
Completed metal framework 694
Porcelain build-up
Final prosthesis
Clinical
Case
09.09.18 pre-op
Key-point :
Selection of proper implant position
12ixx22i vs x11i21ix
1) Available bone quantity and

quality
2) Biomechanical consideration
3) Esthetic consideration
4) Technical consideration
- natural emergence profile
- abutment dimension &
space for substructure &
layering porcelain
09.09.18 post-op
Zirconia
Prosthesis
Final Setting
09.11.04 Final Setting

- Transfer Type
(Direct casting abutment

Single unit)
Fitting of Direct casting abutment
Modification Wax up
Completed custom abutment
Positioning jig
Wax-up
Cut-back
Opaque
Porcelain build-up
Final Prosthesis
Final Prosthesis
Clinical Case
Screw abutments with delivery holder
Select and seat appropriate Screw abutments
with delivery holder
After insertion, tighten it with Ratchet adapter
[Tighten it to 25~30N.cm then Re-tighten after 15minutes]
Seat Impression copings on Screw abutments
Take impression (closed tray)
Seat comfort caps on the Screw abutments
into the impression
Master cast
Master model
Gold-cylinders on the Screw abutment analogs
Consider the distance of opposing teeth,
modify cylinder to its proper height if needed
Wax-up
Cut-back
Opaque
Porcelain build-up
Final prosthesis
Select and insert appropriate Screw abutments
Take impression [closed tray]
+
into the impression
Master cast
Master model
Connect Titanium cylinders
Master model
+
Tray resin framework buccal view
1.5~2.0mm
+
Tray resin framework occlusal view
Buccal : 1.0~1.5mm
Lingual : 0.5mm
Mock-up tray resin framework completed
+
+
Milled zirconia block completed
Rainbow substructure
+
Zirconia core
+
Porcelain build-up
Veneering Porcelain Rainbow substructure
+
Final Zirconia Prosthesis
[Tighten it to 10N.cm]
+
Clinical Case I
Screw Abutment Zirconia Prosthesis
2008.08.27 Pre-op
2008.09.03 Post-op
2008.11.26 Final prosthesis

Clinical Case II
Restoration of a failed bridge

with SuperLine system
09.07.18 pre-op
Key-point :
1. How to restore patients masticatory
function as early as possible.
2. Proper implant position and occlusal
design considering opposing dentition.
09.07.18 post-op
09.09.23 Final Prosthesis
- Ball abutment
Ball abutments
Take impression
Insert Analogs into the impression tray
[Impression coping embedded in impression tray]
After Analogs insertion
Fabricate denture in common method
Examine the interference between inner surface
of female sockets and Ball analogs
Apply the resin with a brush
into the denture inner surface
Position the denture into the model
and wait for initial setting
- Magnetic Abutment
Insert Implant keepers into Fixtures
Seat Magnetic assay on the Implant keeper
Examine the interference
between denture and magnetics.
Relief of denture inner surface.
Examine the Interference
between denture and magnetics
Apply the resin on the relief area of denture.
Clinical Case
2009.05.27 oral exam

Clinical Case
2009.09.04 Post-op
Clinical Case
2010.01.15 Magnetic connection

Recommendation
For Fixed Prosthesis
Transfer or Pick-Up type Impressions
Screw retained Restoration
For Removable Prosthesis (Over-dentures)
Ball Abutment or Positioner
Chairside Intra-Oral Application

Delivery of Superstructure
Superstructure = Abutment + Crown/Bridge/Fixed or Removable Prosthesis
1. Abutment Connection (for Fixture Level impression)
- using Transfer key or repositioning jig
2. Check Contact point(s)
3. Check the fitness of superstructure
- Passive fit ?
- Radiographic Assessment
- Adjust or Remake
4. Occlusal Adjustment
5. Cementation or Screw fixation or SCRP
- Temporary or Final cementation

Repositioning Jig
Contact Point
Fitness of Superstructure
before cementation
After cementation
Occlusal Design
Narrow Occlusal Table
Lateral Force
- Centric contact on Implant
- Flat cuspal inclination
- No Lateral contact
- Lateral guidance on Natural teeth
- Minimal 3 implants for lateral guidance
- Avoid Cantilever design

Connection Type
Screw-Retained Restoration
- Occlusal screw fixation
- Horizontal or transversal screw fixation
Cement-Retained Restoration
- Retrievability ???

Restorative Materials to seal Screw Access Hole
Cotton Roll and/or Cavit
New Product from Dentium
Glass Ionomer Cement or Composite resin

Occlusal Screw Fixation
Screw tightened to torque of 25N/30Ncm

Horizontal or transversal screw fixation
Cement Retained Restoration
Which Cement ?
Resin based Luting cement

e.g. Panavia F, NX3, Clearfil Aesthetic Luting cement, Multilink Automix
Resin Modified GIC

e.g. RelyX Unifast, G-cem, RelyX Luting Plus
GIC
e.g. Fuji IX, Ketac Cem
Cemented Retained Restoration
- It is used as a cementation repair method when:
* In case of screw loosening or if prosthesis repair is needed.
* Prosthesis separation from abutment due to cement loss
* Adding to the interproximal contact surface due to prosthesis loosening
- It provides passive insertion of prosthesis and enhance the adaptibility
A screw type restoration helps to simplify prosthesis repair, including insertion and removal
of the prosthesis if necessary.
Cement type restoration tend to have a stable occlusion and may enhance the adaptability.
However the weak point is that it cannot be removed after permanent cementation.
A dual abutment can be cemented or screw retained.
Combi abutments are cement retained and no occlusal hole is necessary.

- It is used when one implant is placed at different bone level compared to other ones.
- Cement-retained restoration for implant placed at ideal depth

- Screw retained restoration for implant placed at deeper than ideal.
Late Complication
1. Gingival recession
- Resorption of buccal bone wall,

- tension of labial frenum,
- incorrect brushing technique
Tx: Recommend the periodontal and plastic surgery
2. Loosening of the Implant
- Secondary loosening caused by Occlusal factor
Tx: Attention should be given to achieve the Optimised loading,

Regular occlusal adjustment every 3 years
3. Peri-implant Infection
- develop gradually ( Newman & Flemming 1988)

- there is a good chance to treat if any inflammatory changes can be detected
ASAP.
Tx: Patient motivation and good oral Hygiene,

Regular Recall
However, an analysis of the clinical trials of the ITI system reveals that a very small
proportion of failures seem to be associated with occlusal overload. From this analysis
the major cause of late failures could be attributed to peri-implant infections. It was
noted that patients with good oral hygiene tended to keep implants longer.
Australian Dental Journal 2003;48:(4):212-220
Current treatment options for peri-implant infections

1) Antibacterial treatment with systemic antibiotics
2) Rinse with 0.2% Chlorhexidine
3) Surgical corrections
If All failed Removal of Implant

Thank you for your Attention !!!

DENTIUM-practical Course Training - Sylabus

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IMPLANT INTENSIVE

01. What is Implant?

02. Implant Types

03. Dentium Implants

05. Patient Evaluation

06. Implant Selection

06. Treatment Plan

07. Case Presentation

An Implant is a medical device manufactured to replace a missing

A dental implant is a "root" device, usually made of titanium, used in

Dental implants can be used to support a number of dental prostheses,

1941 - Dahl : Subperiosteal Implant

History: As a Vital microscopic technique to study healing events and Microcirulation in

OSSEOINTEGRATION is a process hereby clinically

Others - Zirconia Implants

- ABUTMENT CONNECTED EXTERNALLY - ABUTMENT CONNECTED INTERNALLY

GBR? STABILITY? CONVENIENT?

Soft Tissue Integration

The effects of Implant surface topography on the behavior of

Enhancing adsorption of circulating

1.Implant surface texture

almost like a cylindrical, press-fit implant

Higher initial stabilization

Reduced bone heating

FX3610SW FX4010SW FX4510SW FX5010SW FX6010SW FX7010SW

Taper portion Biological Thread

Bone response 1. conventional loading 0.35mm bone

- Cell: withdrawal tendency

Typical bone loss Platform switching

A posterior superior alveolar nerve

Since they serve as the reservoir of bacterial

Good oral hygiene is critical in implant treatment;

Diagnostic casts & Diagnostic wax-up

Evaluation of tissue health

The volume of the attached gingiva should be measured

Although the sufficient volume of the attached gingiva is

Transparent sheets for Implant Selection

Choose the implant size and length with appropriate

Reference : Australian Dental Journal Volume 53, Suppl 1, June 2008

b. Cantilever vs. No cantilever

At the stage of treatment planning, consider in advance the

Standard Implant surgery protocol : Two stage surgery.

Guideline for one or two staged approaches.

During Tx planning, a plan for a temporary prosthesis that

In case of insufficient soft tissue and/or hard tissue, perform

The emergence profile of the prosthesis should be

a. One missing tooth

Assuming good conditions, however, one-stage surgery is possible.

Advise patients on how to maintain oral hygiene as well

Remember that maintaining oral hygiene in case of

01. Implant Surgical Procedure

02. Block bone hand-on

03. Implant Surgical Procedure

04. Implant Placement Hand-on

- BEFORE SURGERY SET UP

RETRACT INCISION SUTURE

MINESOTA #12,#15BLADE NEEDLE HOLDER

When the interdental papillae are in an

In situations with a more depressed soft

: Long type fixture installation (X)

Minimum 3mm between implants

1.5~2mm 3~4mm 1.5~2mm

Single: in the middle