Lecture 6 03042024.txt

The maxillary interior implants are considered successful. Not when they are only osteo integrated. This is a concept that’s being thought, uh. Decades ago that when an implant is osteo integrated, that’s it. That’s not the case anymore. Implant has has to be fully in function, and, uh. Covers all t...

The maxillary interior implants are considered successful. Not when they are only osteo integrated. This is a concept that’s being thought, uh. Decades ago that when an implant is osteo integrated, that’s it. That’s not the case anymore. Implant has has to be fully in function, and, uh. Covers all the, you know, esthetic aspects of of its position. Besides being osteo integrated, that means there are all the biological issues or biological aspect that we need to take into consideration. In addition to the osteo integration to consider an amplifier and implant successful, especially in the anterior sector Y. To avoid this. This is a 100% osteo integrated implant. You consider this successful? Now. This one. It’s also osteo integrated. I don’t think this is a successful implant as well. What we want to aim to is something like that. Okay. This is a tooth that, um. Is being done very well. The implant, um, let’s say it’s within the, uh. Good or very good placement. Range. There might be some, you know, crystal bone loss there, but we still consider this clinically successful. So what are special considerations for implants in the entire sector? Sector? They require precise diagnosis. The treatment options for implants in the interior sector are tailored specifically for those implants. That means the consideration to restore an implant and tooth number, let’s say three, are different or somehow different than the considerations of tooth number. Let’s say nine. There are more, uh, limitation that are more pronounced when we restore or place implant in the interior sector, besides, um, some other consideration like hard and soft tissue augmentation that might be essential or crucial in order to achieve a successful result. So strategic planning for interior implant restorations is paramount for successful interior implants. And now we all agree that successful means are still integrated and successful in all their biological aspects. Besides, uh, osteo integration. The final prosthesis. Is the aspect that determine if the implant is successful or not. When we place implants where the bone is. That was 20 years ago. It’s not the case anymore. Whenever we are going to place an implant or anyone is going to place an implant, you must have the final prosthesis in mind. This is what we call prosthetic driven implant placement. Now this in the interior sector. Is a no brainer. You have to do it. You cannot place an implant just where the bone is. You have to take the final position of the prosthesis. All the consideration that we are going to discuss in this lecture are going to be in your mind on the paper, on the treatment plan before you place that implant. That means designing the anterior prosthesis precedes implant position determination, and all this must meet the demands of the patient esthetically and functionally. Uh, as we know, in prostate in general, if patient is partially edentulous, the ideal restoration would be. And for a fix partial denture, it might be the most expensive. But we say in general, ideally we want a fixed partial denture to restore, um, uh, a partial dental space in implant. This becomes also the same case. For improved oral health. In general, and. In order. Counting for the number of the implant when we restore a partial edentulous space. Has to be into our minds because the more implants and I. I’m saying this as. Uh, literature. Okay. I will leave it up to you to decide, uh, your opinion about this, that reducing the politics, increasing the number of the implant will increase the retention units. That means the retention unit for the prosthesis and will decrease stress on the supporting bone, leading to minimized complication and enhanced longevity of implant and prosthesis. So what type of. Prosthesis. Can we do prosthetic classifications? We have two types. Major types that we all know fixed and removable with the fixed. We have employment support the president. We have three types. We have. FP1, FP2 and FP3. FP1 is when we restore the tooth only. Major restoration is the structural, uh, shape and structure of the tooth. FP2 is when we over contour this restoration to include maybe part of the root that will make the restoration more elongated or over contoured. When we look at it, ffp3 is when we add the pink esthetics that we will talk about, uh, in a few slides, uh, to the restoration. That means we can add some pink acrylic or pink ceramic to the restoration of the interior crown. That’s when a restoration is considered ffp3 for our removal process. Context removal processes that are fully implant supported. That means that they don’t rely on any mucosal support for their, um, retention on stability. Our five. Is an implant supported removable partial denture that its primary support comes from the mucosa. You can call it implant retained. Okay. But it’s I prefer to refer to it as primary support and secondary support. So primary support is from the uh mucosa from the uh rich. And the secondary support or the retention comes from the implant. So let’s see some examples here. Uh, before the examples. This is just an illustration of the. Of the processes design. This is the FP1. It’s mainly the tooth, only the FP2 is the tooth with part of the root and the FP3. It involves the gingiva as an pink, acrylic or pink ceramic on the restoration. Usually those are highly associated with the concept that we will talk about a few slides from today, which is a few slides from now, which is the smile line. If the patient has a high smile line, medium or average smile line, or a low smile line. Let’s see some examples here. Who knows what type of prosthesis is this? RRP for ffp2 RRP five. This is what you’re going to do next year in the clinic. Raise your voice. Five. That’s correct. This is an, um. Implant retained over denture that is supported by the, uh, soft and hard tissue in the mandible. How about this one? FP3, FP1 or P4. How many? How many of you say it’s FP1? I heard some force here. Who’s who says it’s for? Nobody. All right. This is an FP1. It’s it’s a prosthesis that only restored the teeth. Without any root form or gingival form. How about this one? Before. That’s correct. Those are, um, telescopic crowns that, uh, support the prosthesis. And this one. This side here. What do you think? That’s ffp3. That’s a fixed partial denture that restores the white and the pink aspects. Of the, uh, maxilla. All right, so let’s talk about, uh, lip line here. Are we all together? Okay. Wresting lip line position might vary with age. Okay. Older patients tend to show fewer maxillary teeth and more mandibular teeth while talking and while in the resting position. Um. Prosthetic guidelines considered the incisal edge of the upper and the lower, the maxilla and the mandibular teeth. Position in relation to the esthetics, phonetics, and occlusion. What does this mean? The guidelines generally in removal precedent, say that we can display or it’s ideal to display 1 to 2mm of the incisal edge with the lip at rest in repose position, regardless of the age. But natural tooth position should be considered. That means if the natural if we are restoring one tooth, like, let’s say, an anterior central. We cannot say, hey, I’m going to make it just two millimeter, uh, you know, uh, display when the lip is at rest without looking at the adjacent teeth. What mainly dictates this here are the natural tooth position. Uh, that is adjacent to the missing tooth. Um, is it something like that? Do you think this is? What we’re talking about now. Might be this one. This is the same patient, by the way. After a restoration of the of her smile, you can see 1 to 2 millimeter of the incisors when in resting position. Okay. So. The static zone or the static aspect of the, uh, of the patient is established. On the maxillary teeth while smiling. And on the mandibular anterior teeth while talking. Um. I’m not sure why the picture is over the the writing. So in in general, if the high lip line during smiling or low lip line during speaking. Don’t show. That gingiva. That means the length of the teeth might be not that much of an importance, taking into consideration the esthetic demands of the patient. As the patient becomes older, the maxillary esthetic zone is altered as as we have said. Those are some numbers for you to review. Um. Shows that. You know, 10% of younger patients don’t show any soft tissue during smiling, 30% of 60 years old and 50% of 80 years old do not display gingival region during smiling. The lowly position during speech speech is not affected as much as the upper lip. Only 10% of the older patients show the mandibular soft tissue. Uh, during. Uh. You know, sibilant sounds or during speech. Those are some, uh, you know, some chart as we were talking, uh, majority or like almost 70% of the population are of a medium smile line. And now after this, we’re going to say, what is the low smile? What is the high smile and what is the medium? Almost. Half. The women have the double percentage as men in the high smile line, and it’s the opposite for the low smile line. The men has half the double percentage of the women like 2 to 1 ratio. This is the number of the teeth displayed while smiling. Most of the cases, almost 50% are up to the first molar, a little bit less up to the second molar. Otherwise, very low percentage that would show only the sixth interior or up to the first molar. And I would show you now a case of. This category. If a patient that I treated that has a very wide smile, that shows the molars. All right. Appearance of mandibular teeth in facial position. Um, our among women. Um, you can see interesting in this chart is that it dips, then it goes up, um, with age. All right. Um. I’m not sure why it’s like that. So. Lost my line. The clinical crown clinical crown exposure is below 75%. You see no gingiva at all. You don’t see anything pink when the patient smiles. And this accounts for 20% of the population, the average or the median smile line. As I said before, it’s almost 70%, uh, 69% to be precise, where 75 to 100% of the clinical crown is shown. And you can see also the papilla in between the teeth and the high smile line is full exposure of the teeth and the soft tissue as well. Like you see here, this is a high smile line. This is an average. This is a low smile line and it counts for almost 10% of the population. What is the ideal smile? This is not. A very ideal smile, but it will show some of the concept that we will talk about here. The patient here is not fully smiling. It’s kind of smiling. Okay, so displays full lengths of the mandibular anterior teeth in 70% as we said the incisal curve. From the canine to the canine. It goes like. The curve of the teeth is parallel to the inner curvature of the lower lip, and the incisal curve of the maxillary anterior teeth is touching slightly or missing slightly the lower lip. And it displays the six upper interior together with the premolars in 90% of the cases. This is a a patient that I treated a few years ago. Um, came to me, uh, with high esthetic demands, with some, uh, you know, uh, two crowns in the anterior with some, uh, uh, separation or a dichotomy between those crowns, um, uh, and even, you know, occlusal plane. Um, we tried to treat it with, uh. Some crowns and veneer. And this is the the final result. This is the intraoral picture. We did some, you know, some ginger victime and crown lengthening in the interiors. Um, we changed those two crowns. And this is the. The final result. Um. This was like eight years ago. If you ask me today, I would change some of this stuff. But I would still consider this as a very good result. And this is a shot that will show the surface textures of the restorations. Another case patient came to me those are not implant. I’m just showing that one second. I’m just showing the esthetic concepts that we are talking about here. Those were not treated with implants. Yes, please. For the. Let’s go back. Oops. So it’s a combination of veneers and crowns. It’s a combination of veneers and crowns. We will talk about, uh, about this later. Um, a lot of considerations should be taken into effect here, including the occlusal plane, which I believe is the most crucial factor here. We’re going to be talking about this in, in, in few slides. This is another case, uh, that, uh, I treated also a few years ago. Uh, this is the final result. We did, um, Fitzpatrick Veneers here. Um, this is the mock up. A guided prep to selectively prep the teeth guided by the mock up. This is the placement of the cords. And this is the tri end of the Fitzpatrick veneers. And this is the final, uh, result here. All right. Pre implant prosthetic factors. Those are very important factors that you should consider before. Deciding of an implant placement and let’s say also restoration because it’s a it’s a, you know, it’s a concept that should be approached, uh, together from a prosthetic and from a surgical, uh, perspective, the maxillary. The first thing that we need to assess is the maxillary anterior teeth position, the vertical dimension, the mandibular incisal edge, and the occlusal plane. First the maxillary teeth position. It’s the aspect that should be first assessed in the beginning. If there is a discrepancy in this position of the anterior teeth. We’re talking here vertically and horizontally. It should be addressed prior to start either with orthodontic treatment like let’s say a tooth that is a little bit vertically mapped position. We can do kind of let’s say an extrusion orthodontic extrusion. Just just an example. Um. Or prosthetic intervention that we can do there. Um, if the maxillary incisal edge is modified in either the horizontal or the vertical plane, this may lead to changes in the other elements of the system that we were talking about the video, the lower incisal edge and the occlusal plane. All right, let’s put this into, uh, you know. Together, like the buckle horizontal position of the maxillary teeth in the resting position. Should be assessed first. If it’s two buckle, this will lie. This will lead in the resting position. This will lead in an elevated position of the. Upper lip. A good example of this people who are into soccer is Ronaldinho. Before he fixed his teeth, they were very, very buckled. So whenever he’s not smiling, you’ll see him like that. Because the lip is highly elevated because of the buckle position of the anterior teeth. Well, they fixed his teeth later, and he’s good now. A more palatal position. The opposite of the anterior teeth will lead to an elongated upper lip. We can see here in the design, like in the picture, some of the, you know, parameters that you might consider. The upper lip is one millimeter, uh, you know, more, uh. Pronounced that the lower lip and two millimeter than the lower chin. The vertical position. We’re talking about the vertical position in every post position. So this is not a resting position. I just put this picture just to show you the line that we will talk about here. This is the tip of the canine and this is the tip of the canine. This is what dictates the vertical position, mainly the vertical position of the anterior incisors. It’s 1 to 2 millimeter of the lateral and the centrals lower than the horizontal line drawn between the canine tips. This is. Another case, which is this one that I showed you here. Um. Patient. This was, um. Um. A host of a TV program that came to my office. We restored or rehabilitated her smile. This is the gingival retraction. We did not do any prep there, just very, very minimal enamel plasti. And this is the final restoration. This is the the curve that I was talking about now. That coincides with the curvature of the lower lip. This is the line in between the canine tips. All right. The video. The video or the Oved can call it video. You can call it Oved. You can call it vertical dimension of occlusion or occlusal vertical dimension. Doesn’t matter. It dictates the crown height space for the restoration. And this is extremely important. Especially in cases where we are going to restore multiple teeth as it dictates the number, the size, the position and the angulation of the implant. The mandibular incisal edge position. It’s the overlap between the top teeth and the bottom teeth, which is usually 3 to 5mm. Don’t get, uh, confused with the picture. This is showing. The protrusion, the incisal anterior guidance. It’s not showing the overlap that we are talking about. This is the overset. We’re talking about the overbite where the lower teeth touches the lingual surfaces of the upper teeth. Occlusal plane. We always aim for MIP with canine guidance. Or mutually protected occlusion, which I assume that all of you by now know what is mutually protected occlusion. Right? The anterior teeth protect the posterior teeth during progressive movement, and the posterior teeth protect the anterior teeth. Inviting. All right. Esthetics. We have. Two types of esthetics when restoring anterior teeth pink esthetics and white esthetics. White esthetics by their name are the teeth characteristics and the pink esthetics are the gingival characteristics. And as I said in the beginning, the pink esthetics are more challenging and more hard to accommodate for or to restore than. The white esthetic. And they are essential in our restorative plan. White esthetic involves the shape, surface morphology, dimensions, proportions, sheet position, etc. of the teeth. Themselves and the pink esthetics include the morphology and the texture of the soft tissue. You can see here, um, a restoration that. Counted for the white esthetics and the pink esthetics that we were talking about here. What type of. FP is this one one or 2 or 3? Three. That’s correct. All right. This is a very famous article. Uh, for Belzer. They talk about, uh, pink and white esthetics. I don’t want you to, you know, get confused with those numbers. This is a scoring method that they, uh, proposed in this article. I’m just showing this slide to show you what we look at in pink esthetics and what we look at in white esthetic to form outline or volume, color, surface texture, translucency and the other factors for the soft tissue. All right. Two truths and a lie. This is an ice breaker. I will tell you three things about me. Two of them are true, and one of them is incorrect. Let’s see. I’m a second degree black belt in taekwondo. You don’t think so? All right, let’s see, let’s see. I once meditated for two days at the foothills of the Himalayas. And. I’ve placed more than 4000 implants. I. What do you think? Which one is the false one? The second one. Huh? The third one that most of you think that the first one is correct, right? All right. How many of you think that? I’m not a second degree black belt. Only one? Yes. Yes. Most of you think that I’m a taekwondo player. That’s a good thing. How many things that I went to the Himalayas and meditated two days. How many things? That this is false. Well, good amount. And how many think that placing 4000 implants is a false statement? The majority. Okay, so the lie. This is correct. Actually it’s a little bit over 4000, including the 30 implants I placed in the US. And this is correct. I went to anyone here from Nepal. I went to Nepal to, uh. To a town called Nagarkoti. And I spent there two days meditating. That was in the 2010 or 2011. And that’s a lie. I know nothing about taekwondo, but. But both my boys are. Red belt. So I have three boys. The two older ones are red belt now in taekwondo. Personally, I know nothing about taekwondo. I just see them doing stuff. All right. Let’s go back. The influence of the anterior implant position on the restorative emergence profile. This is. This is the big thing here. This is what I want you to focus at. To look at more. How? The position of the implant. Buckle. Lingual. And let’s say apical occlusal affects the emergence profile of the restoration and subsequently affects the success of our treatment. Whether it was the surgical placement or the restorative face, or both of them. The restorative contour contour of the restoration is a direct function and outcome of the implant position in the two planes that we were talking about. And it depends on how much support. The soft tissue will need. If the implant is located more politely, we will need more support for the soft tissue and we will see in in a picture in a few slides. And if the. If the implant is placed more facially, less contour might be required or it might not be the case. The implant restoration at the cervical aspect should mimic the contours of the natural teeth. As you can see here. Those are implants that this is an implant that has been placed more, uh, you know, Buckley. And then we ended up, uh, with this result because we have to over contour the implant here in order to accommodate for this. And the over contouring will directly affect the. Soft tissue and it will lead into recession. The depth of the implant, which is. Very, very, very important. And it’s if not the most important thing when we are placing an anterior implant with shallow implant, there is one option of creating a big ridge lap like this. With deeper and more apical position of the implant, we will be able to create the contour, the emergence profile of the restoration that we want to. Uh, achieve. So, a quick review. I’m assuming that you talked about this already. How deep should we place our implants? Anyone in the house want to elaborate on this question? Extra points. Ha ha ha ha! All right. How deep should we place the implants? SPEAKER 1 If I go. SPEAKER 0 Excuse me. Can you raise your voice? Anywhere below the bone. Four four. Mhm. Very good. Give him a clap. That. That’s ideally. Ideally, but below what? The crest of bone. Take away the clap. Uhhuh. I know which article you are talking about. This article was measuring how much should we dip it to? Should we place the implant to. To the fear that the papilla will fully fill that space in between the teeth. But it’s not what I’m talking about. Four millimeter. From what? Huh? From the contact point. No. Anyone. So it’s ideally four four millimeter. And it can be three millimeter from the free gingival margin from the. Gingiva. This is an article by uh linguistics Tomas linguistics, where they describe ideally we want 3 to 4mm of the implant placement from the free gingival margin. This is an example of creating an emergency profile using professionalization or professionals. Which is essential. By the way, this is not an anterior implant. I put it here just to show you the emergence profile. This is. Obviously an entire one. It’s not enough to place. A healing abutment on an anterior implant. Regardless, you go place an implant, you open your closet, you see whatever healing abutment, as long as it’s penetrating the soft tissue, I will just place it there and then come take the impression open to send it to the lab and get. No, this will not work. In order to achieve a successful restoration, placement and restoration of an anterior implant, you should have this. And this is. This can be achieved through provisionals. Because we want this emergence profile to be there at the time of taking the impression. And now I will show you in a few slides how we’re going to capture this emergence profile with our impressions. It’s not the usual impression that we take. It’s kind of a method to capture this emergence profile. All right. So some period here. Soft tissue in the emergence profile of the implant are mainly connective tissue that is connected to the bone around the implant junctional epithelium. And circle. Circular epithelium. The junctional epithelium is non skeletonized and the circle epithelium is a stratified squamous epithelium. You can read those numbers. Um I don’t necessarily want to ask about the numbers because different articles will give you an article will tell you one millimeter. Another article with two millimeter. I just want you to know the type of the soft tissue in the emergence profile. And now we come to the divisions of the emergence profile. We have the free gingival margin. This is the prosthesis. This is the free gingival margin which we all know. And then we have the critical contour and the subcritical contour. Which one is more important. The critical or the subcritical. Anybody knows what our critical and subcritical contours. We’re going to show it in the next slide. All right. So the critical contour. Preserves the integrity of the implant soft tissue and is engineered to facilitate close adaptation of soft tissue to the abutment surface and its seal against bacterial infiltration and inflammation. Oh. The buckle critical contour will determine the zenith of the restoration. And the entire proximal contour will determine the shape of the restoration, whether it is, um, a square or triangular shape. The subcritical contour is also very important because inadequate designs of the subcritical contour are associated with inflammation, peri mucositis, and peri implant. Titus. Cement versus security and restoration. This is another question was when we are to restore anterior implants, how many of you think that cement restorations are cement retained? Restorations are better in the interior sector. Don’t look at what’s written here. I will try to confuse you a little bit. How many think that cemented restorations over implants are better than screw retained in the anterior section? All right. How many think screw retained are better in the interior section? A little bit more. And some people. Think neither of them work. All right. So screw retained our superior in general over segmentation because we can avoid introducing cement into the surgical site if it’s an immediate professionalization or the implant biologic with if it’s a definitive restoration. And because of screw retained restorations, have one interface between the restoration and the implant, which is. Where the micro gap. Did we discuss the micrograph before in the articles? Yeah. The Herman article, the interface between the implant and and the restoration. So the cement retained has two interfaces. One is the restoration and the abutment that gets cemented on the abutment. And the other interface is the abutment and the implant. All right. Those are very good studies that have been made. Um, a systematic review by Saylor in 2012 demonstrated significantly more bone loss around cemented restoration compared with screw retained. This is another study by Nissan. Study studied the long term outcomes of cement versus retained implant and showed that a better outcome is for cement retaining crown, and both are good studies. This is a systematic review. This is an RCT. So when we see these kinds of studies where there is a conflicting evidence, what do we have to do? Mm. Decide what’s right for you. Case by case. Oh, which one works? Yeah. Regardless. Regardless like which whatever you feel comfortable doing, you will do it. Yeah. SPEAKER 1 What is better for the patient? SPEAKER 0 What is better for the patient? Any other thoughts here? Guys in the back. When we have conflicting evidence. We have to do one thing that Doctor Fleischer was teaching you to do. Yes. Critical thinking. We have to see. What do we have? And what are the implications of those? Studies on our practice, on and on the patient health or oral health. So let’s see here. Segmentation margins. The Academy Academy of Osteo Integration. You know, there was a consensus that if the margin of the segmentation and again, we’re talking here only about cement retained restorations. Okay. If it’s deeper than 1.5mm from the free gingival margin, there is a very high chance. That this will threaten the outcome or the success of the implant. Okay. Why? Because there is a higher chance of of. Uh, leaving remnants of cement in the sulcus in the Perry implant. Soft tissue. The main factor that may cause cement remnants to remains in the Perry implant sulcus are, but not limited to, standard abutments. Don’t use them, please. Or they call him stock abutments. Just don’t use them. In the interior sector. I encourage you to not use them. Not in the interior, not even in the posterior I. I just don’t think that a a stock or a standard abutment fits all the conditions the concept itself is not conveying to me. So in the interior sector, just don’t use them. Don’t use them because there is a lot of undercut that might trap the cement and it will cause a lot of big problem. This cement that gets left in the sulcus can cause a lot of problem. And now, during the past few years, a lot of studies are coming and they’re showing more and more how crucial this is to the peri implant health and how this remnant cements contribute to the formation or to the, uh. Condition that we called peri implant. Itis deep sub gingival margins. As we talked here 1.5 and below showed high level higher level than uh less from um cement remnant. That doesn’t mean I’m not telling you to place the, the the the cementation margins 1.5mm or above. That doesn’t mean this. This means that anything below 1.5 is a high risk. But that doesn’t mean that if it’s less than 1.5, it’s a less risk. We’ll see now in a few slides what we should do there and the poor visibility on the radiograph. This is. It’s just obvious. If you see cement on the radiograph, you have to take it out. Okay. And also the, uh. The ARP included the residual cement as a risk factor in the classification of the peri implant disease for the development of peri implant mucositis and peri implant sites. This is a very. A very important and interesting study. We will not be able to discuss this. Totally today. But. Please. If you are interested, go ahead and read the full article. It’s a very interesting article by Lenka vicious talks about the influence of the margin allocation on the amount of undetected cement. Um, the main finding of this study was that despite careful cleaning, various amount of cement remnants were present on the abutment restoration complex and in the peri implant tissue. Regardless, whatever you do to prevent this cement, there was always some cement. And the funny thing about it is that the researchers that participated in this study. All the cases included in this study, the researchers believe that they had removed all of the excess cement. You know, what does that mean? This is not working. What does this mean? If all of you do a restoration and all of you think that you have removed all the cement and then it it comes out that all of you have left. That means that we are not able to gauge whether or not we remove this cement. Unless there is a way to do so. So how would you remove the cement and make sure all the cement remnants are removed? Let’s see suggestions. You have number nine or number eight implant patient with an implant comes to your practice next year and tells you, my periodontist sent me to you so that you can restore this implant. So you go ahead. You take the impression, you say you know, what cement retained is more esthetic. There is no access. Screw. I will just do cement retain. You pick up the best custom abutment, let’s say custom abutment. And it’s, you know, uh, golden in color. It will not show any grayish under the soft tissue. You have thick bio type or thick phenotype of the tissue. Everything is ideal. The case comes from the lab. You put the abutment, you put the cement, you cement the crown, you finish. Now how you’re going to make sure that you removed all the excess cement. Mm. You think you can’t? Why? Huh? So are you saying that you. You’re gonna wait until Perry mucositis starts, and then you’re going to decide if there is cement or no. Um, no, no, I, I like your idea, but I’m telling you why. Mm. Why? What does the X-ray show you? SPEAKER 1 If. On your blog, huh? Radio. SPEAKER 0 Yeah, but if you are taking an X-ray to see if there’s excess cement, what does what does the PA or the x ray show you? Two dimensional. What does that mean? You don’t see everything. What do you see in the x ray? Enter proximal. That’s it. So in the x ray we will see only the medial or the distal. If there is a cement. All right, so what about the buckle and lingual? How are we going to make sure there’s no cement left there? Only if you open a flap. That’s why. And your answer is correct, by the way. It’s technically impossible. Impossible to remove all the cement that remains in the sulcus. As impossible as this elephant walking on this rope. There is no way that you can tell me that you are 100% sure that you removed all the cement. Unless. You open a flap and there are people who open a flap just to make sure that there is no excess cement. There is no way, no matter how you isolate, no matter how many x rays you take, no matter how you do, you might be able to minimize this a lot. But there is no way that you can tell me. I removed all the excess cement around implants. I’m talking. Hey, I’m not talking around teeth. Why? Why implants are different than teeth in this aspect, and cementation risks cementation of restorations. What’s different? We’re biologic with. What’s the difference in the biologic width between teeth and implant? The position of the biological. What about the fibers? What fibers? PDL is missing. I’m with you. We’re not talking about PDL. Inter dental. Did we hear about Sharpies? Fibers? Yeah. So it’s actually there is no. Significant attachment of the biological. To the restoration. Around implants. Where is in teeth. We know that there is an attachment. That means if you put the cement around the. That’s why when you probe around implants, you will see the probe going all the way down to the implant platform. Okay. There are recent studies that are showing kind of what they call tissue adhesion, which are very interesting to know, which they claim that. There is a kind of adhesion through hematoma zones in between the soft tissue and certain types of restorations. They are talking specifically about highly polished zirconia, and they say that there is a kind of attachment or tissue adhesion. They call it between the soft tissue and the zirconia. But this is not our our discussion today. So if we cement around the implant because of this long junctional epithelium, the cement will escape from the cementation margins and it will go all the way down to the implant platform. Now imagine opening a flap exposing the implant platform to removing to remove the cement. Why would you do that? That’s why. Before. That’s why the role of the cement is the same. Like the calculus. We all know by now that calculus is not by itself and a geologic factor for periodontal disease disease. It’s only a predisposing factors that will retain bacteria and cause irritation to the soft tissue, which subsequently would cause periodontal disease and implants. It’s basically the same. The cement acts like the calculus around teeth. It retains bacteria and it irritates the peri implant soft tissue, which would lead in the future to peri implant disease, which basically is peri mucositis and peri implant itis. Some techniques to reduce the cement. Rubber dam. So they. It looks. Acceptable, right? Um. So Robert Dam, they place it on the abutment. They cement it. And then. Today we have all this cement that we removed. What’s an issue that you see here? Yeah. The rubber dam is stucked under the abutment. Another technique. Some people will place, um, like two chords. Around the implant cement and then remove the cords because they think that the cord will prevent the cement from running all the way down to the implant platform. This is another technique. Which involve making a replica of the integrity of the crown. Anyone is familiar with this technique. So we make we we we grab whatever you want, Blumhouse. Let’s say we injected inside the intaglio of the Crown. This is not not working. Here is it? We injected inside the integrity of the crown. We let it set and then we remove it. And now we have a replica of this interior, like a replica of the abutment itself. And then we take this replica. We fill the crown with the cement, and then we put it inside the crown, and we remove the excess cement extra orally. And then we take this crown and we cemented. On the abutment intraoral. Exactly. First, it doesn’t guarantee that you don’t have excess cement. You minimized it a lot, but you cannot say that I don’t have excess cement. And one issue other issue with this technique is that when they did a study about it that I’m going to show now, they found out that lots of cases of these cementation. Why? Because when you put when you put this cement inside the ground. Do you think that all the spaces in the interior are filled with cement? No. Now imagine putting less cement. You. This involves a lot of. Possible complication. This is another study by Link Devices as well. Found out using a retraction cord and replica abutment that I was telling you about. Result in less and detected cement on the cement retained prosthesis than using rubber dam. However, rubber dam resulted in less excess cement in the soft tissue. So. Total cement removal is not possible because it’s. We cannot. We cannot make sure that we removed all the cement. Both methods can lead to possible clinical failures. Entrapment of the rubber dam. Dissemination during cement removal. How to minimize residual cement. Avoid standard abutment or stock abutments. This is what I was telling you about. Just don’t use them okay. For intraoral cementation okay. Opt for custom abutment with supra gingival. Cementation line or margins that follow the contour of the peri implant tissue, or what we call equi gingival or para gingival call it. Whatever you like, but make the cementation contour. Equal gingival follows the free gingival margin of the soft tissue around the implant. This is the only way where you can have a full visibility for the margin. You can see the margin. And you would be able to control the amount of cement left. Not necessary. So. Or 100% avoid residual cement. By following my secret recipe. Are you ready for the secret recipe? Make sure. Make sure to do it. You will thank me a lot. You will not. You will have zero access cement. Zero. And don’t tell anybody. The secret recipe is cruelty. Just do security, guys. You will save yourself a lot of troubles. Okay. Especially now we have all kinds of abutments. Even with some mal positioned implants, to a certain degree, we might be able to overcome this with a screw retained abutment. So what is the impression technique? This is what you’re going to do in your practice. If you are going to take an impression of an interior implant okay, you have to capture the 3D anatomy of the implant soft tissue and duplicate the sub gingival profile. How you do that. Let me tell you something. The moment you take the healing abutment from a central incisor implant. Within seconds, the soft tissue will start to collapse. Seconds. So now imagine taking the healing abutment or the provisional, bringing the impression coping, putting the impression coping, taking a bite wing to check if the impression coping is seated, filling the tray with the impression material and taking the impression what? What will you capture? Nothing. The soft tissue. If you if you leave the. There are cases where if where you leave the implant without healing abutments for minutes and the whole implant will be covered with soft tissue, it collapses right away. So how do we take the impression? This is one way which I usually use. We all agreed now that we’re going to use a provisional. To form the emergence profile of the anterior implants, not a healing abutment or what we call a custom healing abutment, which is designed like a shape of a cervical area of of a natural tooth. It’s made out of the based on the emergence profile of the tooth itself. After the extraction, or there are some other ways of making it. Anyways, now we have a provisional number nine implant. We take away the provisional. We attach it to the analog. I’m assuming we all know what is an analog, right? Everyone here knows what’s an implant analog. Yeah. All right, so this is the analog. It’s a replica of the implant that’s used to the lab. Sorry, that’s used in the lab. For the lab technician be able to make your final restoration. So we put it here and then we fill it with impression material. Well in this pictures they show heavy body, light body. Honestly, it doesn’t matter. I sometimes do it with putty. I just take the provisional. Attach it to the implant, replica to the analog, and then grab a bowl of putty and put it inside of it and shape. I just want to capture that cervical area because when we put the provisional, the soft tissue has been formed based based on this provisional. So we want to capture. This thing, which is the emergence profile. Once it’s all set, we remove the provisional. We put the impression copying and then we fill the space. In this example they filled it with pattern resin. Easier way. Just fill it with floral okay. And then cure it. And you have this. This is now your impression. Copying what’s different in it is that it holds. The shape of the emergence profile, even if the soft tissue here collapsed during doing this. Once you put this back, it will take its shape again. Okay? And you take the impression and this is what you have. Another example would be. SPEAKER 2 Um. SPEAKER 0 Doing this intra orally by injecting some flushable. And the emergence profile if you don’t have a provisional. I don’t use this method. I prefer the other one. And then here is their final impression. Everyone got the technique. For the what? Not necessarily. Not necessarily. Okay. One minute. Can we all hear what your classmate is asking? Please? Can you say that again? Yes. No. Thank you. That’s a very good question. Um, I usually do all my implant cases or let’s say most of them with a digital, uh, impression. That means I use a scan body for for the impression. So here’s what I do. You bring your patient? The patient has. The custom, let’s say a custom healing abutment or a provisional. Okay. You take the scan. Let’s say implant number ten has the custom healing abutment. You take the scan with the healing abutment on the implant, and then once you have the scan. You trim only the emergency profile area. Only this area. Okay. You trim it on the scan and then you go to the patient mouth. You take this. Custom healing abutment and you right away. Scan the emergency profile. This way. You’re not wasting your time scanning everything. You’re just scanning this 2 to 3 millimeter radius, a circle, which will take. Milliseconds. You just take the healing abutment out or take the provisional out, and then you scan the emergence profile. You leave no time for any collapse in the soft tissue. This way you have. This way you capture all the emergence profile around the implant. And then another scan would be, depending on the system that you’re using, would be with the, uh, with the scan body to determine the position and the, uh, angulation of the implant. Did we all get it? Those last two slides. Keep them. You’ll need them, believe me. Even for a. Molar implants where the healing abutment is very wide. You will have to do this in order to capture that emergence profile. Otherwise, the patient will come back after a few months and tell you, hey doc, I’m having food trapping in between my teeth where the implant is. What can I do? And this is most likely because of the under contour of the restoration, because of the collapse of the soft tissue. Okay, let alone any other, uh, uh, factors that might be involved here, like implant disease or, uh. Any other issues around the implants related directly to the design of the restoration. Any other questions? I hope this was not boring. Uh, maybe most of you will end up not placing. Maybe. I’m saying people who place already implants might be more comfortable, but interior implants are very hard to, uh. The treatment plan. I tried here just to give you an idea what you have to do when you are to take those impression and restore those implants. So now. One last thing I want you to leave with. Or two more things. Why do we need to know all this? Why do we need to see all this articles. Why do we need to think critically? Why do we need to read the book? That Doctor Fleisher gave you. Go read it. Don’t say it. I’m telling you, if you want to get. And you will see that this year and next year. If you want to guarantee. A good grade and doctor Fleisher courses. You have to read that book. You have to read that book. Okay, go read it. It will help you apply lots of good concepts in your life and in your practice. Now, why do we need all this? In order to avoid this. And this. And this. Do you guys think that we really need to avoid this? How many of you think that this is acceptable? None. Okay, what if I tell you there was a study that has been made comparing restoring posterior teeth with one implant versus two implants. That means for a molar, we have one implant in every root. And they got. Well, interesting results. Finding an evidence that supports your arguments does not make it. Evidence based. You know. What does that mean? A guy who placed that crown will come and tell you I have closed margins. There is no look. Look at that x ray. It’s all closed margins. There is no. Periodontal disease. This is an evidence. But does this makes make the argument valid? I will not say no. I will just leave it up to you. Just take this message home. If you find or if we find anything that supports our argument. That will not make it necessarily evidence based. It might be most of the case, evidence based, but not necessarily. Not all the evidence is evidence. Okay? So this is where I come from. It’s a small country in a place. Maybe you would not want to go there now. Uh, it’s called Syria. It’s in the Middle East. It used to be a beautiful country. This is the area where I come from. Latakia. Uh, this is homes. This is also Latakia. And this is Palmyra. Let’s see now. Some very important people. American celebrities that are. That have Syrian origin. I’m not saying that they are Syrian. They are. They might have some Syrian roots. Okay, who is that? Paula Abdul. The singer and a television star. How about that? Was this? Yes, that’s Teri Hatcher and our guy. And. Yes. SPEAKER 3 Yes. SPEAKER 0 He’s of Syrian origin. He has some Syrian origin. And. Mitch Daniels, former Governor of Indiana and former president of Purdue University. University. And yeah. Former Cleveland Browns quarterback and. Believe it or not. His biological father is Syrian, from Homs. This is my classmate in Spain around 2008. One of them. This guy Javier, is practicing in Miami. The others are in Spain or. International. This is my best friend, Gerard. I named one of my boys after him. Yeah, and this is my. 2023. You’ll be taking this picture. Guys, I know you already took this picture. No. You didn’t take this one in the white coat ceremony. Oh, yeah. Guys, you’re the. SPEAKER 3 First here. SPEAKER 0 I forgot. Never mind. All right. You’ll be taking this picture in July. Or June 28th. Okay. And this picture is a. SPEAKER 3 Year from. SPEAKER 0 Graduation. Thank you. Please, if, uh, if any of you have any questions or anything that I might be helpful, please send me an email and I’m happy.