Dental Implants Lecture PDF

So everybody knows about the brand of Mark implant. And we're talking about his work that started in the 1950s, became commercially available in the United States in 1986 and in Europe just slightly earlier than that. But the reality is that we have evidence of dental implants being placed as early as 2000 BC. We have. We have skeletal remains that shows us that dental implants, usually using gold, um, where we're done way back in time. Of course they didn't. Some of them lasted, as shown by the evidence, but we're quite sure that they weren't as successful and as predictable as what Bran and Mark came up with. And there are others along the way who also had other ideas about using dental implants, and we'll talk about those in a minute. So this is the random walk implant. This is the ﬁrst random walk implant that came onto the market. This is the classic Branham walk implant. It is a screw retained implant. It is a machine surface. So it's relatively smooth and it has this on top. This is what's considered an external hex connection. All right. This is so there are two parts to a dental implant. Right. Essentially what we're talking about. One part is the implant itself. And the other part is the part that allows the implant to connect so that you can put a tooth on top of it. That will function right. This external hex brand mark. Who was not a dentist. All right. So he didn't understand the concepts associated with dentistry. He didn't understand the concepts of retention, right, and resistance as it pertains to a dental implant. And so he never really thought about it. So he placed this external hex on the top of a dental implant so that he could because we somebody asked him about it and he said so that he could drive the implants because he was doing thousands of them in his studies. And so he was able to drive the implants into the bone very eSiciently with this external hex on top. That was really the the reason why he came up with it in that way. And then the dentists, once it was proven as a process, had to work with it for an extended period of time. So what is osteo integration? We hear this term all the time, so I see. Integration refers to a direct structural and functional connection between ordered living bone and the surface of the implant itself. So this all this black is the titanium of the implant. And this this is the bone itself. This is under very high electron microscopic um magniﬁcation. And you can see the very tight. Uh, relationship between bone and the implant, and there is no other type of living tissue interspersed between the bone and the implant itself. And that is osteo integration. So who discovered osteo integration? 1950s. In the early 60s, Professor Brannock was engaged in a blood ﬂow research of the rabbit ﬁbula. This is really interesting in in this respect that this is this is yet another example of how a major breakthrough in the scientiﬁc community came about, sort of by accident. Right. Brandon Mauk was not studying how to place dental implants in the jaw. Right. He was he was studying about blood ﬂow in the rat ﬁbula. And he had placed these titanium chambers containing an optical system that trans illuminated a thin layer of bone and marrow, and the blood ﬂow was observed by microscope. So this is made of titanium. It's placed into the ﬁbula, and you attach a microscope to it and you're able you literally able to watch the blood ﬂow. Right? So that in and of itself is pretty impressive. What what he was doing. But what he noticed was that the chambers couldn't be removed from the bone once it had healed. And the observation of bone growing in intimate contact with the chambers led to the identiﬁcation of osteo integration as a real biologic phenomenon. So it was a totally just, you know, extra, um, observation on his part and an incredibly astute observation on his part. He was not the ﬁrst one to notice something like that. While he is acknowledged for his contribution in the discovery and for having created the term osteo integration, others prior to Brandon Mock had made the same observation regarding regarding titanium and bone broth. Credit is the ﬁrst to use titanium and Leventhal in an article titanium a metal for surgery, both observed the tendency of titanium to be diSicult or impossible to remove from bone once healing had occurred. The diSerence between them and Brandon Mauck and the reason why you know brand name but not their name is because Brennaman not only made the observation, but then he went a step further because he thought what could be an application that would be useful in science for this? Right. Because the the titanium was, um, healed in such a way that it wouldn't come out very easily. And Brandon Mark, to his credit, went outside the box and started thinking about something that wasn't even related to his topic. Right? It wasn't a dentist, and he wasn't studying about about the jaw. And he said, you know, maybe we could use this for dentistry. So hats oS to him for that. This is the ﬁrst major study and it was published in 1977. And this explains the entire protocol. They talk about the Branham implant and the, uh, the evaluation process that went on for more than 15 and 18 years in the in the healing in humans. And it was it was an incredible study. But what most people don't recognize is that. By the strictest of standards, this study doesn't meet some of the criteria that you would expect today. Right. And what I mean by that is this is showing you he was going through an evolutionary process with the design of the dental implant itself. So within this ten year and the 15 and the 18 year follow ups, there were all diSerent types of designs of implants that were being utilized. It wasn't a single implant design that he stuck with throughout the entire time. And so today, people would criticize something like that and say that this is a this is a fault within the study because you're using diSerent variables. But in reality, it worked well and we got a lot of useful information associated with it. So let me ask you all a question for a second. If you knew someone who needed a hip replacement, what kind of questions would you be asking the surgeon placing it? Forget about dentistry for a minute, but if you had to have a hip replacement, or if you knew somebody that you loved that needed to have a hip replacement, what are the kind of questions that you would be asking the surgeon before they placed? Speak up really loud. SPEAKER 2 For this surgery. SPEAKER 0 What is the success rate for this surgery? So okay. SPEAKER 1 How many have you done? SPEAKER 0 How many have you done? How long will they last? Yep. Normally with this. Can you function normally? Okay. You may ask, what kind of material would you would you use. So all of these questions are the kinds of questions that you're going to be asked when a patient comes in and wants to have a dental implant placed. Because people today, with the internet available to them are much more savvy than much. They have a much better understanding of all the dental procedures that you're going to undertake, and they will take the time, just like you would if you were having something done to make sure that they understood what was happening. And they'd ask all these kind of questions. And these are all really good and important questions, right? But the, um, the question. So the question of a of success rate. So what kind of what success rate do you want to know about? Do you want to know the the published data on success rates? If you're asking that question. Yeah. SPEAKER 3 Probably the success rate that they've seen. SPEAKER 0 Rather than. So you probably want to know both, right? You probably want to know what is what is the scientiﬁc literature that tells you what the the average success rate of that of that procedure is. And you also want to know personally their success rate to whether their success rate is lower or higher than what is the the standard. Somebody have a hand? SPEAKER 1 Yeah. Yours? Insurgents? Yes. SPEAKER 0 Exactly. Right. So you want to know both both of those things? They're all they're all important to know. Anything else that you might want to know? Yeah. SPEAKER 2 What are the. SPEAKER 0 Risks associated with it? Sure. Let me ask you something. Are all hip replacement? Are they all the same? Why are they diSerent? The anatomy. Well, the anatomy of the patient is diSerent, but I'm talking about the hardware. The hardware itself. Would you imagine that they're all the same? Probably not. Right. So we know that dental implants are not all the same. There's a whole bunch of dental implant companies that are out there. Do you want to know which brand they are using to place in in your body, whether they're using the really expensive one or whether they're really using the cheap one? Right. And maybe there's a diSerence in success rate between the cheap one and the expensive one. And so you want to know details, right? So if you were designing a new dental implant, what are the important features you would need to consider? SPEAKER 1 Yeah. What's that? SPEAKER 0 So ICAO integration. You want to know if the implant osteo integrates? SPEAKER 4 How much bone there is. SPEAKER 0 Well, I'm talking about your designing a new implant. I'm not talking about. You're placing a dental implant. You're designing a new implant. So what are the things that you have to think about? The surface. SPEAKER 1 And what? SPEAKER 0 What do you mean by the type? Because you're designing it. Move in blind. Okay. So what the surface is going to look like? SPEAKER 2 How many of the materials. SPEAKER 0 Okay. What kind of material are you going to use and how bio compatible it's going to be? SPEAKER 1 How you're going to attach and possibly remove any prosthetic. SPEAKER 0 Right. What's the attachment going to be? Well, how am I designing that attachment. Because that's going to be really important to the dentist. Right. The surgeon is going to be really concerned about the surface area, and the restoring dentist is going to be really concerned about whether that's a diSicult attachment or an easy type of attachment or dimension. What kind of dimensions am I going to utilize? What am I going to make available? Yeah. SPEAKER 2 Versatile. Can I use any? SPEAKER 0 Okay. Am I going to design this implant so I can use it both in the anterior and posterior areas? Yeah. So can you maybe. SPEAKER 2 Like if you need to be changed or not or. SPEAKER 0 So say that again. SPEAKER 2 Of the inﬁnite. Would you place it? Oh, okay. Sure. SPEAKER 0 Okay, so what is going to be the long term success of the of the dental implant? What other features would you consider to be a really important. The the the dimensions, both the the diameter and the length of the of the implant. So there are a lot of diSerent things that you have to think about when you're looking to place a dental implant, right. So you're looking at the the surface associated with it. You're looking at the shape of the implant itself. You're looking at the composition of the implant. What is it actually going to be made of? What is a surface area made of? The surface composition, the connection to the prosthesis, the location of the implant relative to the bone margin is actually a really important concept. And you're going to be reading all those articles, and most of them are going to be related to that in some way or another. And so you're going to have to think about that when you're designing your implant. Where do you want the interface of the implant and the connection. Right. There's the abutment connection. Where is that going to be relative to the bone. Because you're going to be able to decide that when you're when you're placing it. So here's the implant. There's the abutment. There's the crown. That's some cement that's on there. This is what current implants look like. These are all diSerent shapes and types of implants over the years. And when I say over the years, I'm talking about probably from the early 1960s on, there's a blade implant, which was very, very successful. When you were looking at it. In the 1960s and 1970s, Lincoln, who was in the Boston area and did a large number of these. Right. So his success rates were considered to be really good. Back then, his success rates will probably be in about the 70 percentile range, which today doesn't sound very good, and it isn't compared to what we have. But at the time when you have faced if you are a patient that was faced with the prospect of having a denture that didn't ﬁt very well and had very few options available to them. The thought that you might be able to get something in their mouth that had a 70% success rate sounded pretty good, and lots of people avail themselves of it. We have these cylindrical types. Some of them are smooth surfaced. Some of them have a a coating on them. Some of them are screws. We have something called a sub periosteum which actually does not go into the bone itself. It it's like a saddle that rests on top of the bone. Right. And then we have these kind of crazy things that also are implants. This is a European design that was used also in association with some blades as well. And then you have this round type of implant that's very small, that's also in use today. So lots of diSerent shapes. There are lots of things that you're going to have to learn about this year to start to understand what's involved in in dental dentistry associated with implants. And the the surface of the implant itself is of a critical importance to the to the success of the of the dental implant. Should it be threaded or should it be what we call a press ﬁt? Press ﬁt was all smooth sides, and you literally you're pushing it into the hole. You're pushing it into the osteotomy. That's a press ﬁt. And the threaded is one that gets screwed into place. The material itself. Not all dental implants are made out of titanium. There are other materials that are now available and you need to understand that. There's the thread pitch, which is the and we'll talk about it in a little bit, but it's the angulation of the thread and the distance between the threads that have potentially some signiﬁcance. Whether or not the length of the implant matters, whether or not the diameter of the implant matters, whether or not the implant is what we call a one stage or a two stage implant. And whether or not it's a bone level versus a tissue level. These two things are not related. Exactly. And they're not the same thing. How many people know what the diSerence between a one stage and a two stages? Okay, so not too many people. SPEAKER 1 All right. SPEAKER 0 The original Branham implant was an external connection, right? It had a hex sitting on top of the implant. And then there are also implants that have internal connections for abutments. All right. There are internal hex and internal octagonal. There are tie bases and custom abutments. These are all things that you're going to learn about in this semester. And then in attaching the crown to the implant, you have two basic options. You can either have it screw retained or cemented. And I understand that none of these things necessarily make sense to you at the moment, but it is our expectation that by the time this course is over, you'll understand all of these things. And then this concept of platform switch versus standard diameter abutments. Right. So we'll talk about all of those things. The original brand mark implant was a machine turned to implant made of titanium. This is what it look like. So it's considered to be a fairly smooth type of surface. It's titanium but it's fairly smooth. Right. And it was. Machine's ﬁnished. The press ﬁt. It was also a popular type of implant. At the same time that Brian Moore came to market and was, and it was usually with a textured or roughened surface. So this was very early on. Axel Kirsch in Germany was one of the ﬁrst people to utilize this type of a design, and this type of an implant versus the machined implant, so he was challenging brand mark on his concept of what the surface of a dental implant should look like, and even whether or not it should have, uh, screw threads or whether it should be a press ﬁt. So these press ﬁts you literally. You took a mallet, which is a fancier name for a hammer, and we tapped or smashed the implant into the into the hole or the osteotomy. Right. And that that was the press ﬁt. And they ﬁt very snugly and they worked really well. The screw thread the design. The actual osteotomy itself was slightly undersized, and so when I mean slightly undersized, what I'm talking about is so you have the body of the implant itself, right? Imagine for a moment if you took those threads oS and you had, in essence, what was a pressed ﬁt, you would have an osteotomy that would allow the body of the implant to ﬁt. Now you put these threads on and you make no accommodation for these threads, so that that osteotomy is still the same exact size as the press ﬁt. But now you are going to have those screw threads cutting directly into bone, right? And you are going to gain stability by doing that. Right. So the osteotomy for press ﬁt is exact. It allows the implant to ﬁt into the osteotomy. The osteotomy for the screw thread design is slightly undersized. If you measure from the tip of the thread to the tip of the thread on the other side, that distance is slightly greater than the distance of the diameter of the of the osteotomy itself. So this external connection is 0.6mm in height. Right. Think about what you've learned. Have you taken ﬁxed yet? Are you taking ﬁxed. Yes. Okay. So you know about. You're not going to prep a tooth right. That has 0.6 height and expect a crown to sit on top of that and stay. Right. So this was a major design ﬂaw when it came to dentistry. And it was a major problem that dentists dealt with for probably about a decade. For the most part. There were a couple of alternatives, but a lot of people were using random walk and they were having problems because of it. All right. And if you look at the branded system, this was all screw retained. And so this is a screw that is retaining the crown. And it goes inside a screw which is the abutment which goes inside a screw which is an implant. Right. So it's a screw within a screw within a screw. Right? Lots of places. Lots of screws for a single crown retained. Uh, implant, retained crown and a lots of possibilities for problems as a result of that. So the original machined surface versus a roughened surface. The composition of the implant surface. The original mock implant was machined relatively smooth surface. And then you had these other types of implants that had roughened surfaces or were coated. Now we're talking about strictly roughened surface here. This is the scanning electron microscope of an implant surface. This one is the machine's surface. So you can see it's relatively smooth. And B, C and D are diSerent designs of roughness based on the the way in which the roughness was attained oS of the implant and what brand you were using. So what would be an advantage of an implant surface being rough over smooth? Why bother doing this? So when you say it increases the integration process, how does it increase? So it's increasing the surface area. Right. So that was that was the ﬁrst thought that came to mind. So on a microscopic level, you see all of these undulations and you know little crevices. And so there's a much greater surface area for the potential for bone to interact with the surface of the implant than on this machine's smooth surface. So it made perfect sense to have this roughened surface. And of course, the results baw baw it out. But in addition. There may be something else as well. So, but the retention is going to be coming from that increased surface area, right? Potentially. So is that the only advantage associated with it? And it turns out that it's not that we actually see a chemo tactic diSerence between a rough and surface and a smooth surface. Right. And while you don't necessarily have to understand all the details about it, this is just diSerent companies with diSerent surfaces, diSerent roughness. Right? This is the machine surface that we're talking about. And the others have varying degrees of roughness on the implant. And the point of this slide is to explain to you that not all implant companies have the same degree of implant surface roughness. So if you reach the conclusion that roughness is important. Then you may want to pay attention to the particular brand that you're dealing with, and whether or not the amount of roughness is the one that you think is important to use. Right. There are these biomarkers that we use in association with diSerent aspects of osteoblasts activity. And what we ﬁnd is that roughen surfaces tend to increase these biomarkers. Right. And the conclusion that we draw is that not only is there this mechanical aspect because there is a greater surface area that we're dealing with, but the roughened surface, for whatever reason, seems to interact with osteoblasts in a positive manner and causes more activity to take place. So roughened surfaces are pretty uniformly considered the standard right now, right? So this is a this is a machine surface. Dental implant, and this is a roughened surface dental implant. All right. And this is measured with, um resonance frequency. And we will talk about that in a future lecture. But just for the moment, understand that conceptually what that is doing is it's giving us some objective data as to how stable the implant is in bone. At any given time. This is the moment that the implant is initially placed. So this is what we call the initial stability. It is purely a mechanical retention. There's nothing biologic that's happened at that moment. It's just that it's it's formed and it's staying in place as time goes by. There are other things that are happening to that site. And what you see is that there is a signiﬁcant dip instability on a machine surface implant after it's initially placed. And why would that be? So you place the implant, right? You cause some trauma to the area. And so you're going to have some osteoblasts that are going to be dying in that area. And you're going to have some osteoclasts activity that's taking place as well in that area initially. So you actually are starting to lose stability, and it takes about three months before you start to see an increase in the biomechanical stability that takes place. So you have this initial phase and then you have this secondary phase. And with the with this particular brand of roughened surface, you, you also see a dip in stability, but it's not as bad as the smooth surface or the or the machine surface. And then at three months, it kind of evens out at a high level higher than the the machine surface. Right. So this is about the roughness and about the stability of the implant. And this is why conceptually, when you were looking at this data, you would never want to restore an implant at this early phase. And you would only start looking at restoring it at a later phase. So with this roughened surface, you could say, well, at three months, I'm probably at a point where I've reached the maximum amount of stability that I'm going to have, and so I can restore that case. At that point, with the original machined implant, you really had to wait six months before you could feel comfortable in knowing that you had achieved the maximum amount of stability. So there are diSerent ways in which you can attain a roughened surface on a dental implant. It's not just one way to do it. In diSerent companies use diSerent methods. There's titanium, plasma sprayed, sandblasted, and titanium oxide. These are all ways to get a roughened surface. I'm going to. I kind of bore you with these slides, with these graphs, but they're really important information. So this is one company. Who has two diSerent ways in which they developed a roughened surface. All right. They have. What they ﬁrst came out with was what they called an SLA, which was sandblasted and acid etched, which is which converted that smooth surface to a rough and surface. And then eventually they came up with SLA active, which was sandblasted, acid etched and also chemically modiﬁed. And so they looked at this stability that I'm talking about for both the SLA. And the SLA active, and what they found was a signiﬁcant improvement in the SLA active over the SLA. And now look at this information. So we have the primary stability. That's when the implants were placed initially. And that's purely a mechanical stability that's taken place. Right. And then over time you will have in both cases you lose some stability. And in the case of the SLA you lose a lot of stability, right. For a while. And. And with the SLA active, you have much less loss of primary stability. This is the primary stability. This is the SLA and this is the SLA active right. For the SLA active the secondary stability. This is the biomechanical stability that takes place. You have a much more rapid much more rapid increase in that secondary stability. And it reaches its plateau at a much earlier phase instead of months. We're looking at weeks for both of these. So this secondary. Stability that takes place. Which? Which is from new bone that's forming by four weeks. You have an incredibly high level of secondary stability in the SLA active. If you're waiting for the SLA, you're waiting at about 7 or 8 weeks. So what's the signiﬁcance of that? Who cares? Does this mean that the overall success rate of this dental implant is going to be better, with the SLA active over the SLA? What is this data show us? SPEAKER 1 We're. SPEAKER 0 Somebody raise their hand? Yeah. SPEAKER 4 You have to restore the hmhm. SPEAKER 0 So it says nothing about the ultimate success rate. Right. There is no diSerence in the ultimate success rate. The diSerence is in the amount of time you have to wait before you can restore it. Now, some of you have already treated patients and many of you have not. But I can tell you that one of the ﬁrst question, I mean, just think about it from the perspective of a patient. If you were a patient going in there, one of the ﬁrst things that you're concerned about, of course, safety is above and beyond anything else. In long term, success is most most important as well. But right after that, and very close to those things, is how long is this whole thing going to take? All right. Because I got a whole I got a space here and I want it done. I want to take care of. And if you're telling me that I have to wait eight weeks before I can get it restored, or three weeks before I can get it restored, I'm choosing three weeks, right? If the overall success rate is the same, nobody wants to wait longer if they don't have to. If it's a lower success rate with the three weeks, then sure, then you'll wait, right? But if it's the same, or maybe even better, then why not? Why not do it at three weeks? Three weeks is not a very long period of time to have to wait to get it restored. So these are important right. So and just to reiterate this does not result in a higher long term success rate but rather a faster stability enabling the restorative treatment to begin earlier. They recommend as little as three weeks. Their data shows that in as little as three weeks you can start restoring these cases. I will tell you that I personally would not restore it. Three weeks. We're looking at averages of numbers, right. And some people are going to take a little bit longer on this curve, and some people will take a little bit less time. And I don't know that person that's sitting in that chair, whether it's longer or less. So I'm going to err on the side of caution and and wait a little bit longer, but only maybe another week or so. Yes, this is. SPEAKER 1 A graphic from. SPEAKER 5 The manufacturer. SPEAKER 0 It is, but it's published data. It's a these are published studies that back up this graph. All right. So the peer reviewed all published information. But it's a good question to ask. Right. Where is the information coming from. So titanium is not the only composition of a dental implant. You also have zirconia. What exactly is zirconia? Is it a metal? So zirconia is actually not a metal. It's derived from the metals or corneum. And if you look at it on the atomic chart, you'll see zirconia is very close to titanium on that chart. So it's produced by a process called reductive chlorination. This results in a ceramic zirconium oxide, which is known as zirconia. Right. So as the Konya implant is not a metal implant, it is a ceramic implant. I mentioned to you about thread pitch right the distance between threads. Some companies come up with these designs where the thread pitch is very diSerent than in other companies. Right, and they use it as a selling point. These days, I will tell you that the the data does not seem to support, to any great extent diSerences in thread pitch as being of any signiﬁcance in terms of stability or long term success for dental implant. But companies still tend to make a big thing out of it. At some point it may become a bigger issue, right? Ultimately, what dental implant companies are trying to do is get to the point. And as you'll all see in a short period of time, we have to use a series of burs to gradually increase the dimensions of the osteotomy and implant. Companies are looking to be able to place an implant directly into bone without cutting the osteotomy at all. And if you have to, maybe only once, right? That's the goal. They're not there yet, but part of it may have to do with the thread pitch eventually, right? So now let's talk about bone level versus tissue level for an implant. This is a bone level implant right. How did it get its name. Because the top of the implant is that the bone level makes total sense right. Tissue level. Why do we call it that? Because the top of the implant, where the abutment is going to communicate is going to touch. The implant itself is at the tissue level, right. That is the diSerence between a bone level and a tissue level implant. So this tissue level implant this is all one piece. So there is no abutment implant interface here at the bone level. It is only at the soft tissue level. And that may or may not be important. Right. You're going to read a bunch of articles that's going to give you the answer to how important that that actually is. And relative to the bone level implant, if it is important and if it is a problem, how have we dealt with that problem? So the abutment for the bone level implant is at the osseous crest. The abutment is coronal to the osseous crest and at the tissue level. Then we have what we call two stage versus one stage, right? I asked earlier about who understands the diSerence. So in the one stage approach, the implant abutment traverses through the mucosal tissue at the time of placement. Tissue level implant almost always is a one stage implant. On rare occasions you will submerge it and put it under soft tissue. But it's diSicult to do and it's diSicult to maintain. And if you're intending to cover it up, then you're probably not going to want to use a tissue level implant. The two stage approach the implant is initially submerged with the tissue closed kernel to it. The implant will need to be uncovered and the abutment attached at a later date. So the Brannock implant that you saw was a bone level implant. And that had a healing screw that got put on top of it, a closure screw. And then the soft tissue was covered over the implant and sutured together and allowed to sit for over six months. If it was the mandible and even longer if it was the maxilla. Right. So. So that was the brand mark. And that was the vast, overwhelming majority of implants that were placed initially starting in the 1980s. With that system was always a two stage process. So you place the implant, you covered it over, you allowed it to heal completely, and then you went back and you had to uncover it. You had to anesthetize the patient. You had to make a surgical incision. You had to expose the implant, and then you had to place in abutment a healing abutment that connected to the to the implant at that time. So a bone level implant could be either a one or a two stage process. So I just described to you the way Brandon Mauck did it. And that was a two stage process. But it is also possible that at the time of surgery to place a healing abutment that will traverse through, its a long enough healing abutment that will traverse through the soft tissue and in essence convert this to a one stage process, right? Because now you will not suture over the top of that healing abutment, but you will suture around it and allow it to heal, and you will have access to it immediately and continue to have access to it. Right. So we'll talk about the diSerences and the advantages and the and the disadvantages associated with it. This is a one stage because you can see it that this is a healing abutment that is traversing through the soft tissue on the day of the surgery. And you can access it at any time. And you don't need a second surgery to expose it. This is a two stage. And this is actually a. A tissue level implant. This is why I said rarely, but occasionally you could do it. But the important thing to remember is that this is this is being submerged. And so it is considered a two stage process. If you have to do some sort of grafting around the implant, then you are going to make this a two stage process because you want to isolate that so that you improve the outcome of the graft itself. This is just a quick video showing the two stage. SPEAKER 6 This movie shows the two stage dental implant placement method. In this situation, the ﬂap is raised to expose the bone. The bone is drilled to prepare it for the implant ﬁxture, which is placed and then covered with a cover screw. This cover screw is very thin and just covers the opening of the dental implant. The ﬂap is then repositioned over the implant and sutured into place. After the appropriate waiting time, the implant is exposed, the cover screw removed and replaced with the healing cap. The tissues are then repositioned around the healing cap and allowed to heal. After the appropriate healing time, the healing cap is removed and the crown base and the implant crown are placed on the dental implant ﬁxture. SPEAKER 0 So this is that two stage process. And it's showing you that at a later date it's being exposed. And now a healing abutment has been placed. And now the tissue is around it. And you can see the healing abutment after that ﬁnal suturing has taken place. And so that's considered the that would be considered a one stage if it was done at the time of surgery. But that's also what happens for the two stage. Does that make sense? Anybody have any questions on that? One versus two. Stage. SPEAKER 1 Okay. SPEAKER 0 So the concept of biologic, with which I know you're starting to hear about and what that means is around a tooth. We have the bone level. And then we have connective tissue that is inserting into cement above it always right. Bone is never exposed and connective tissue is always above it inserting into the tooth itself. And then above that you have the sulcus that includes the epithelial attachment. Right. That's a cross-sectional diagram of a tooth. When we look at a dental implant, obviously, regardless of what you may hear or read by some implant companies that are telling you that they have a connective tissue attachment between an implant and a and the soft tissue, you can't we don't have that. It's not available at this time. Right. Because it's titanium or zirconia. And neither one of them will allow for. Neither one of them will allow for actual connective tissue insertion. So there is a big diSerence between what's going on around the neck of an implant and around the neck of a tooth. So here you have connective tissue, but it is parallel to the implant itself, circumferential. And so it doesn't allow for quite the same type of barrier as around the natural tooth. And so that may have some potential consequences and implications for long term stability of a dental implant and whether or not it's susceptible to any kind of a bacterial insult. All right. The other diSerence is that the bone is in intimate contact with a dental implant, as opposed to a space between the bone and the tooth, which we call a periodontal ligament, which is connective tissue. It is a suspension ligament, right. That allows for some mobility to take place around all teeth. A dental implant is not supposed to have any movement at all. If you have movement of a dental implant, then you have a failed dental implant needs to be taken out. Right. So those are basic diSerences between the two. Placing dental implants. The signiﬁcance of an angulation error right when you place a dental implant, this is showing you a nine degree error on a 13 millimeter long implant. It comes out to be a. You are two millimeters, 2.04mm further away at the apex than your intended location. Now is that important? So sometimes sometimes it's not that important. Right. This is not the greatest situation that we have here, but it is probably something that is clinically acceptable. And you will be able to restore it with an angled abutment. SPEAKER 1 Okay. SPEAKER 0 But other times it does make a big diSerence. All right. This is a dental implant that's actually contacting the tooth adjacent to it. Right. So this individual who actually was a dental student opted to have a dental implant placed to replace a congenitally missing lateral so that they wouldn't have to have prosthetics done on the adjacent teeth, only to have prosthetics done on the adjacent teeth, because the person that placed the implant, not me, the person who placed the implant placed it too closely. And invaded into the the periodontal ligament and touched the surface of the tooth, causing it to have an antibiotic problem requiring a root canal. All right. So they make a diSerence. And this case is just the most horriﬁc case that I've ever seen. Right. This is real. This came into my oSice the day after the implant was placed because the patient woke up. The patient had been put under sedation for the implant. Placement was still numb when they left the oSice. And beginning that night when the anesthesia wore oS, they started having severe pain and the dentist wasn't answering their phone calls, probably because they were busy packing, leaving, going to another state. But um, but yeah, patient came in having no idea that this had happened. They they bisected the tooth. Now you're going to be in the lab and you're going to be seeing simulation wise about cutting through simulated bone, and you're going to also have the opportunity to cut hard tissue, real teeth, right? When you're in the clinic and you're going to be cutting the simulation bone at speeds of about 600 to 800 rpm and try cutting a tooth at 600 to 800 rpm, you're not going to be very successful. It's going to be a lot of smoke. The ﬁre department's probably going to show up because the smoke detectors are going to go oS. So in some respects, you have to give the surgeon a lot of credit for being able to have cut right through a tooth. Right? Not a good outcome. But the question is how can you prevent this? Right. And that's what we are teaching you. We are teaching you the basics to understand how to place dental implants and how to do it not only successfully, but predictably and safely for your patients. All right. We are going to be utilizing all of the latest technologies. We are going to be taking an intraoral scan of the patient. We're going to take a CT scan. We're going to merge this data together. And you're going to do that in the simulation lab starting next week. And so this is what it looks like before the information is merged. You have the optical scan. You have the CT scan. And this is what it all looks like when you put it together. And you start planning out the case and you can see the implant. Three dimensionally because it's a Cat scan, and so you can look through it in diSerent. DiSerent dimensions. So this is all great right. Terriﬁc. We planned this and for many years we could we could do this. But how do you take this information and bring it to the patient's mouth. Because for a long time that part was missing. We could plan it and it would look great. But then we went into the mouth and we sometimes ended up with disasters because we didn't do what we had intended. Well, if we create a surgical guide based on that information, which the technology readily exists today, you will see and utilize this technology on your simulation case. And then when you're in the clinic as well, and you will place the implant more or less. When we say exact, we're scientiﬁc in nature. It's not exact. There's some variance, there's some degree of variance, but it's very small. The tolerance for the discrepancy is minimal. But we are basically going to place it exactly where we wanted to place it. So this was the original the original computer lab that we did the ﬁrst year we ran through this. This is an actual clinical case that was placed, and this is showing you that the implant is exactly where the where the surgical guide told it to be. And this is placed by a pre doctoral dental student. This is placed by a pre doctoral dental student. They didn't assist the faculty. When you do these in pre doc you will be the operator and the. The faculty. The faculty will be in the assistant chair. Right. You will do this from start to ﬁnish, because you will have had this course that has given you the opportunity to understand every single step of the way and the rationale behind it. And this is showing you exactly what we're talking about. This is a pre doc student. This is the faculty and the faculty and staS writer Penny. And she's standing in the assistance position helping helping out when necessary. SPEAKER 2 This is. SPEAKER 0 All right. And this is. This is what our goal is, is to get you to the point where you're going to be able to place these implants within a few months. All right. We're going to take a ﬁve minute break. Doctor Noah is going to set up I thank you for your attention this morning. We. SPEAKER 1 Can go right to you. Hi. SPEAKER 4 These, uh, like, are the things like biomarkers. I mean, they're level, for example, low level of alkaline phosphatase. Yeah. Contraindication for placement. SPEAKER 0 So we're not going to be measuring that. We don't look at those. SPEAKER 1 Um. SPEAKER 7 All right. Let's let's let's let's let's continue. Good morning everyone. So now is the good stuS now that Fleisher left. Well. So for those of you who do not know me, because I got this a couple of times, people bumped into me like, do you work here? I'm like, yeah, I'm actually the chair of the Department for General Dentistry. So you're going to see a lot of me. Um, I wore a lot of hats when I ﬁrst started here at Bu. I used to teach operative. I taught ﬁxed for a long time. I taught occlusion for a long time. And then, uh, Doctor Fleischer and I, we developed this course together back in. We started in 2016. The course actually became available in 2017. And we've been doing it together since. Um, I'm a prostate, honest by training. Doctor Fleischer is a periodontist. That's why it's kind of like this beautiful marriage where he's going to talk to you about, like, bone and yucky stuS. And I'm going to talk to you about crowns and how to make people smile. Right. So we kind of bridge that together. I know you heard a lot of new words today. And, you know, we're glancing over them like, oh, I see integration osteotomy abutment. And you're like, I have no idea what was just happening. And that's normal and that's ﬁne. I promise you, we're going to take you through each and every one of those terms, explain to you what those terms mean, how do they or how do they apply to not only the scores but to you clinically as well? So if you feel overwhelmed right now, it's totally okay. And as Doctor Fleischer mentioned earlier, if there is any questions or anything that does arise, by all means by please just feel free to either email one of us, email him. Um, we will get back to you if we need to meet and talk about it. We'll meet and talk about it. All right. So I'm going to sort of maybe focus more on what Fleischer sort of gave you a very quick overview I'll try to focus more on. Some of the things that he said, just so that you have a better understanding of some of the terms that you may have heard for the ﬁrst time. So, you know, we talked brieﬂy about if you were to design an implant and, you know, you heard external hex and you heard like a platform of the implant and all this kind of stuS. So if you look at an implant in general, whether it's a has a machine surfaced or whether it has a roughened surface, whatever, there's typically 2 or 3 parts to an implant, right? There's the body of the implant, and that's the one that has the threads on it. That's easy. There's the apical portion of the implant. The reason why I point this out here is because you saw on some of Doctor Fleischer's slides, some of them had holes right at the bottom. And that's so implant goes in, grows in between. You saw that some of them had like almost like a ﬂat surface. Right. And again, each company is going to tell you why, like the iPhone 15 is titanium. That is like amazing. And Samsung was like well then we have like seven cameras in the back. They're just trying to it's just telling you we're doing it diSerently and this is why we're better. If there isn't necessarily anything to prove that if you have a hole or if you have a, you know, a ﬂat surface versus a, you know, the just like Fleischer's talked about the thread pitch, right? There isn't really a lot of research to say that the diSerence in the thread pitch will increase or decrease your success, right? So that's the apical portion of the body portion. Now, the two important parts of any dental implant. And for you to really, really, really understand, at least from a restorative perspective, is the color of the implant and the platform of the implant. All right. The collar of the implant you're going to read about in those articles, for sure. And a lot of what the caller has to do kind of ties into a little bit about what Doctor Fleisher said about tissue level versus bone level. Right. So the caller, if you think of a caller of the shirt like that's the top part of the shirt, right? So it's the same thing. It's a top part of the implant. And whether that top part in this case you have sort of what looks like a roughened implant, but it has this polished collar, right. There are some designs that are roughened all the way. There are some designs that are polished all the way. What's the diSerence? What's the signiﬁcance? Why would I have something that's rough? But then the collar is polished, right? Fleischer's third lecture, or the third lecture for this course is all about that. The four articles that you are assigned to read. Two of them are speciﬁcally about that. So we're not going to talk necessarily about the biological impact, because that really has to do more biological than anything about that portion, about that just yet. However, it's just for you to understand, at least when you're talking about just basic. Today's introduction to the dental implants. At least you know that if you look at an implant, there's a body, there's a collar, and then there's a platform, the platform, which is basically the top of the implant. Right. So. Think of it as. You know, uh, you're opening a diSerent water bottle, right? An Aquaﬁna versus a Poland spring versus a Fiji versus or whatever. They all essentially have a cover that goes on top of it. But if you get that cover from a diSerent water bottle and try to screw it onto a diSerent water bottle, it won't go on, would it? Right? Because the platform is a little bit diSerent, right? So each platform is a little bit diSerent depending on the implant and even within the same implant company. So let's say in this case these two implants are Nobel biochar right. One of them has an internal connection. One of them has sorry. Both of them have an internal connection. One of them has a tri channel. Right. So it looks like a triangle. And one of them has an internal hex. So do you see it looks like a hexagon. Okay. So what that means is what the. And I'm going to spend as much time as we need to get this concept because this is probably one of the most important concepts. Right. What this means is that platform is what's going to connect whatever crown or restorative component that you're trying to attach the implant to into the implant. All right. So. When Fleischer was showing you when Britain First originally came out, it was the what? It was the external hex, right? It was that external 0.6 0.7mm connection and that was resting on top of the platform. So here's your implant. The top of it is the platform. And then it had a half a millimeter or 0.6mm external hex. And that's that connection that can allow it to connect to a crown, an abutment, a denture, whatever it may be. We'll talk about restorative components a little bit later. Right. In this case or speciﬁcally in this implant, it's not residing on top of the implant. It's inside the implant. So I don't have an external 0.6mm. Rather I have a hole essentially inside the implant where whichever restorative component is going to ﬁt inside of it. All right. So the platform is in the connection. The platform. Right. Because the platform is essentially the top of the implant, the connection is either external or internal. I can tell you this. What? I can't believe it's 2024. Happy New Year, by the way. Um. We haven't used external hexes in. I mean, they are still on the market, but I the last time. I've seen one or restored one was 20, 12 or 13. We barely use them anymore. At least in the US. They're not used as often, right? Now, again, as I mentioned earlier, you know, you someone some you have a Google phone, you have a Samsung phone, you have an iPhone. Right? So what's going to diSerentiate each phone from each other? What's going to diSerentiate diSerentiate each internal connection from one another. Some internal connections are going to look like a triangle. Some of them are going to look like a hexagon. Fleischer showed you something was like an octagon. It had eight sides, right. So each company is going to diSerentiate itself, and it's going to tell you why. My implant with the six sides is much better than his implant with the four sides, or with her implant that has the nine sides and so on and so forth. Right. But you as the dentist, and whether you're the surgeon or the restorative, will have to understand and weigh your options on why, you know, implant A is better than implant B or implant B is better than implant C. And we'll when we talk about restorative, I think 5 or 6 lectures from now we'll show you the diSerence. I mean, I'm going to talk about the diSerence in connections in the next two slides. But why you would choose one over the other. All right. So the connection mechanisms external hex resides on the platform. Right. So again here's the platform. Right. It's the same on all the implants. The external hex is right here. That's this portion okay. In the internal connection. Do you see how you don't have that on top? Rather it's inside. All right. So that's the diSerence. The connection is either an internal or external connection. And whether it's on top of the platform or inside the platform. Is this making sense to you guys? Yes. Okay. Good. So what is the function of a hex. Right. Because we said it's either an external hex or an internal hex. What is the function as that of the hex, just like Doctor Fleischer is explaining to you. So. If you were to prep a tooth, right? And I don't know why you would prep it down to half a millimeter. But if you were to prep a tooth and you only have half a millimeter, do you have any resistance or retention form? You've got nothing, right? So in essence, that's why there was a screw inside of a screw inside of a screw. Right? Because you have very, very, very, very little resistance and retention form from an external hex perspective. Now, if I ﬂip that design and instead of having that 0.6 on top, but I ﬂip it inside and it's much more than 0.6, you see how short this is versus how deep this internal hex is, right? I'm increasing my retentive proﬁle. All right, so the idea behind the whole hex, whether it's external external is really that it's the retentive mechanism. It also serves as an eSective anti rotational element. So the fact that it's a hex has six sides right. So when it goes on bless you it doesn't turn sideways. Right. And when we go into the SLC and we try on some components, I'm going to have each and every one of you do this. You're going to put whatever it is, whether it's an abutment, whether it's an impression coping what. And I know a lot of these terms don't make sense yet, but whatever component you're trying to ﬁt on top of the implant, once you put it in, you shouldn't be allowed to move it sideways. Think of it this way. You have an implant that in the lab sends you a crown, and you, as the restorative dentist, have to put this crown onto the implant. Should you be guessing where the buckle is and where the lingual is, and where the muzzle and distal is? Or should it only ﬁt one way? Right. So the fact that you have this anti rotational component is that if you put it on wrong or if you put it on right, it shouldn't move sideways because as we're going to talk in seconds, as we know when we grind we're not necessarily putting favorable forces. Right. So if I'm grinding side to side, I may maybe putting exclusive forces on the tooth. Right. And Fleischer showed you we don't have periodontal ligament. So what's going to prevent this from moving. Does that make sense. Okay. Now this is also important from a physics standpoint. The hex is the weakest area in the entire implant body connection. Why? If it's external it's 0.6 and it's pretty thin. It's not even half the thickness of the platform right. And if it's internal, do you see how much I have to take from the body of the implant itself for it to ﬁt? Right. So that portion of the connection, whether it's external or internal, is the weakest portion. Which means. Typically if something is going to fail, whereas it's going to rear its ugly head at its weakest spot. Right. So. Things to consider. How wide is the implant? How you know how big is my crown? What kind of forces on my placing on the crown am I, you know, is this in proper angulation? Is the four are the forces directed down the long axis of the tooth? Right. Because if you get the case afterwards. Right. And in the case failed, in order for you to restore the case again and make sure that it doesn't fail again, you have to know what caused the failure. Right screw loosening and fracture of the implant components have been noted with traditional external hex more than one internal hex, right. So one of the ﬁrst signs, one of the ﬁrst signs that something is going to go wrong with an implant is typically screw loosening. So much literature about this. Right. Before the implant fractures or before the crown breaks or anything. Typically, the ﬁrst thing that's going to happen is that the screw that's holding that restorative component, whether it's the crown, the abutment, and so on and so forth, that screw gets loose ﬁrst. And as a dentist, the ﬁrst thing we do is the patient comes back and we just tighten the screw and be like, you're all set. And they come back again and it's it's loose again. Right? I can't tell you how often this happens. Take that as a sign. If the screw is loose, something's wrong. Whether the occlusion wasn't adjusted properly. It's more often than not, at least from one of the biggest articles that was published on this. Goodacre published said the number one reason for sclerosing is mal occlusion. Right. You didn't check the occlusion properly. And the ﬁrst thing that's going to happen is that you're going to get screw loosening, right. Again external hex because of how short it is, that restorative, that retentive component, you're going to have more trouble than an internal component. So the ﬁrst external component and again 0.70.6, um, that on top of the platform. Right. That aspect of it was the original benchmark design. They came out with an octa, had eight sides instead of six. They came up with something called a spline, which you can also tell, you know, probably just looking at it physics wise, it probably would even be worse than a hex because of all of these small ﬁns that are coming out. If you have exclusive forces that are unfavorable to the implant, right, that they will fracture. But like I said, you know, part of this is evolution understanding. Hey, we tried this. What if we add two more sides? Is that going to add it. Maybe add to the anti rotational component. But it it isn't didn't necessarily increase retention. So what if what if we do a spline. Would that be better. So we keep trying to evolve with a process. And you know whether it's the same company or a diSerent company and how are they going to diSerentiate themselves. So what are the advantages of an external hex. Again, long term follow up data. Right. You saw benchmark sort of came up with this idea in the 50s. So we have, you know a lot of data compatibility, multiple implant systems. So when all the implant systems came out, whether it's three AIS, Zimmer uh, you know, Toman noble bio care, you name it, all the implant companies that came out there, their original model was an external hex, right? Because we've dealt with a lot of these. We have enough solutions at this point. We know how to ﬁx them. We know usually what goes wrong. The disadvantage is that we have much more screw loosening. So we have a lot of more restorative complications, higher prevalence of rotational misﬁt right. And inadequate microbial seal because it's such a short retentive proﬁle that you're never going to get this good seal. How about internal hex. So our internal connection. So when typically when you're talking about an internal connection you're talking about an internal hex Morris taper, which is what you see here is kind of like um, almost like a press ﬁt, but for the restoration. Right. So the internal connection of the implant has a speciﬁc angulation. And then the abutment or the crown that you're trying to restore has a very similar, slightly smaller. Right. And then you press it into place. Right. So you know, remember that short implant that Fleisher showed you that drilled into the tooth a short one. So those implants are actually here in Boston. They're back on they're actually down the street here. They're very, very successful. And those short fat implants you place one in that will last forever. Right. And so we're going to talk about, you know, width and length and all that kind of stuS later in this presentation. But those implants from a restorative perspective are like this. You press, you press the restoration into place. So as a restorative dentist, what's tricky about that? You really are essentially guessing where buccal and lingual and misaligned distal are, because you don't have anything that will guide you until you know it only goes in six ways one, two, three. Like right around the hex. It's a Morris taper. Okay. These don't. That we they barely exist anymore. Because as we move and as technology evolves and as we've become, um. Smarter, if you will, and also more. Uh, I don't I don't know if I'm phrasing this properly, but maybe we value time a lot more, right? It makes sense that if something ﬁts one way, I don't have to just try to guess where the positions are, right? So within these internal connections we have the six point right, which we have an eight point we have a 12 point, we have a tripod. That's the one I showed you in the beginning where it's like three points. We also have Cross-ﬁt which is a four. So again they're all going to be diSerent. Whether it's six, whether it's eight, whether it's like you see here looks like a triangle. So they call that a tri channel um which has its own problems. We'll discuss a little bit later. So what are the advantages of internal connection? We have less restorative, uh, complications. So we don't have screw loosening as much. We have a better microbial seal, better joint strength and more platform switching options. Not going to talk about this yet. Fleisher is going to talk to you a lot about that next week. Right. And you're also going to read about it in the article. But essentially what it means is like you can switch diSerent types of implants with diSerent types of abutments and crowns. It has more ﬂexibility in terms of, you know, I can only place this type of crown with this type of implant. In internal hex, you have multiple options, not just one option. The disadvantages that we don't have as much data, which isn't true anymore. It's like I said, it's 2024. We've been placing internal hexes since at least at least the 80s. So we have at least 40 years worth of data. So I don't know that this statement is necessarily true. It's true in the context if you're comparing it to external hex, right. But in the grand scheme of things, if you have 40 years worth of data, you have enough data. Yeah. And certain designs and diameters are weaker than others. Right. And the reason why this is important is remember how we said what's the weakest part of the implant. It's that connection aspect. Right. So if I were to go back and let's look at this tri channel. Do you see how between where the implant connection is and where the external aspect of the implant is? Do you see how thin this portion is? So on an implant that is 3.5mm in diameter versus an implant that's ﬁve millimeters in diameter, you see how this distance is a little bit wider than that distance right. So if I have a tight space let's say I'm restoring or I'm replacing a misaligned lateral or a missing lower anterior tooth has a very narrow diameter. And I'm placing an implant that is narrow, that has this design. When something's going to fracture in the implant, it's going to fracture right there because they don't have enough thickness to it, which is why they actually discontinued this implant. Right. It was very easy to restore. It only goes in one of three ways. It's very simple. It's very straightforward. But especially with the three ﬁve diameter, there were there were a lot of restorative complications. They still actually kind of sell it. But like you almost have to like know someone at the company to buy it. Um, they switched everything to internal hex. And this is Nobel Baker. We used to use this implant when we ﬁrst, um, started this course in 16, 17 and 18. I think we made the switch to conical. And we've been conical since. Okay. So implant platforms. So the original benchmark protocol. Right. They, they did what they had these several external hex and then they connected them together with a ﬁxed prosthesis. So these were typically done for uh patients who are completely evangelists. They weren't done for a single tooth replacement. Right. When this original concept came was was for it originally for patients who are fully evangelists. That's why if you if you Google brand mark and you like click on Google on videos. He's like his tagline. And he was like very proud of this. Um, is like, no one should die with their teeth in a glass of water. Right? And his concept was, is that if we have these implants, we can connect them together with a bar. That's kind of what you saw in one of Fleischer's panel x rays. And then a prosthesis can be on top of it. Right? So the external hex was designed was to help screw the implant into place. In fact, that portion, that 0.6mm wasn't done to restore it. That 0.6mm that was on top of the platform was so that it can be held into the drill. That kind of also reﬂects to you that when he originally was thinking of this design, it wasn't thought of for restoring a tooth, right. Which clearly it wasn't. Right. So. I like, as I've mentioned already 2 or 3 times, you kind of understanding now the implant type and the internal connections is very company dependent. Right. So you saw Fleisher show you this, this is uh, these that are sticking out are sort of tissue level. This is what they call bone level. This is strongman. This, uh, implant system is, uh. So strongman and Noble body care, our number one and number two in the world in terms of sales and implant placed, uh, in patients. Depending on who you talk to from each company, they'll they'll tell you who's number one and who's number two. Um, but typically strongman is number one, and not because of the strongman itself. That's a whole diSerent conversation. But anyways, um, the reason why I'm telling you about this is they have these diSerent terminology. The concept is the same. An iPhone, a Google phone, a Samsung. The the concept is the same. It's a device that you can download apps on the. The OS may look diSerent. The operating system may look diSerent, the interface may look diSerent, the terminology may look diSerent, but the concept is the same. So once you understand the concept of what an implant is, what the thread is, what an internal connection is, how an abutment or a crown connects into the implant once you understand that concept. Company A is going to tell you that, oh, we don't call it an abutment. We call it a restorative. Whatever. Right. They're all going to come up with this like fancy way of explaining of how they phrase it diSerently. The concept is the same. So you'll see that here with strawman they call the collar neck. Right. If you look at Nobel biochar, they don't call it a neck. Right. And with strongman, there'd be, like, regular neck, wide neck. That's for a tissue level. But if it's bone level, they call it narrow connection. Regular connection. That's just how strongman calls it. But if you call noble biker and be like, I want a narrow connection or a wide neck, you'd be like, they're just going to be like, they're going to hang up on you because they don't use those terms. They'll understand what you're saying, though. Do you understand what I'm saying? So the concept is the same. In any implant company, whether it's Nobel, strongman three, AI, Zimmer, whatever. Implant company. You end up working with in your practice. Okay. Once you understand this concept, it's going to apply. The diSerence is, is that they're going to name it something diSerent. So don't get locked into under oath. It's only a connection. So connection or a caller only means that it's a neck because that's a mistake you're going to do. All right. So like I said Noble Bichir, they have diSerent connections. They have conical connections. And for them it's see what they called it narrow neck or narrow connection. Here it's NP narrow platform, regular platform. So every company is going to name it diSerently. The concept is the same. Okay, you heard Fleischer talk about an abutment, and you heard me say the word abutment a couple of times. You heard me say screw retained crown. Cement retained crown. You heard him say that earlier. So what are all of these? Okay, so I think I think at least we can all agree that we established the implant itself. Yes. Okay, good. So in order for you to get a crown on top of that implant, you have to connect something into the implant so that a crown can sit on top of it. Does that make sense? Okay. That is what is called an abutment that. So number three here. That's an abutment. Right. There are diSerent types of abutments. Obviously, this is not that easy. Nothing in life is easy. You're going to hear all diSerent kinds of abutments, but when you hear the term abutment, that's what that's referring to. It kind of looks like a prep tooth right. So it's going to go into this implant. It has its own platform right. Which is its margin. Right. So that when I get a crown I want to see it on top of this abutment, it has to have a sealed margin. Right. Same concept of you prepping a tooth with Doctor Brown. And then you have to have a margin that's at least 1.5mm. If you're doing an old ceramic to two millimeters, so that when you see the crown on top of it, you get a seal all around, same concept. You're placing an abutment into an implant that kind of looks like a prep tooth, right? It has enough height. So it has resistance and retention form. Right. Versus that 0.6mm. It has a margin that goes around so that when the crown seats I don't have any leakage, I don't have any microbial issues, I don't have any bacteria that would leak in. I don't have cement that will, you know, if I'm using a soluble cement, that the cement will will be soluble and then the crown would fall oS. Is that making sense? Now, now you not understand what the term abutment is. Does anyone have any questions about that? I'll explain it again. We're good. Okay. Yes. UNKNOWN Right. When is. That. SPEAKER 7 So think of it this way. If you have to place an abutment on top of the internal hex, right? Is that what you're saying? Yeah. So you have an external hex, and then you're going to place an abutment on some of the external hex and then a crown on top of that. So that's a screw inside of a screw inside of screw. That's what Fleischer was showing, right? All right. So two things to think about that. A space. Right. Because okay, so the implant was here and now I have a 0.6mm. And then I have to put an abutment. You know that at least has 3 to 4mm if not longer depending on which tooth I'm restoring. And then I have to have at least 2 to 3mm of the thickness of the ceramic. How much room do I have? From the tissue level to the opposing dentition. So that's one thing to keep in mind. The second thing to keep in mind is the more screws you have, the more complications you're going to have. Right because you saw or you'll get to see in a couple of weeks in the lab how small these screws are. The one thing and this happens every year, Fleisher and I, when we go into the lab, we're like, we put everything on your bench and be like, do not open anything until we tell you. Because as soon as you guys open it, these screws fall on the ground and you can't even see them. They're so tiny. And with that, if you're grinding or if you're moving side to side, or if you, you know, bid on an olive that still had the pit in it or something like that. And so you're putting a force that is unnecessary on this tooth. That small connection of that tiny screw is the ﬁrst thing that's going to loosen. So the more screws I add, the more restorative complications I'm going to add. Does that make sense? Does that answer the question. Okay. So this is what would be what we would call typically a cement retained restoration. Right. I have my implant I have my abutment I have my screw that's going to hold the abutment inside the implant. And then the crown that gets cemented on top of the implant. Right. So that's why you kind of see this hole here that's so that the screw can hold it in place. And then typically so I don't get cement on top of it. We usually put um Teﬂon tape, which is kind of plumber's tape or sometimes cotton, although please don't use cotton. But we used to do that, I don't know, 15, 20 years ago. It really if you ever have to take the crown, it smells so bad. Right. So don't use cotton, use Teﬂon tape. And it's a lot easier and cleaner to, to use. So essentially what we would do is we would put Teﬂon tape so that the top of the screw is still accessible. So you don't get cement inside and you don't get cement inside this hole. So why are we doing that though? In the oS chance and hopefully never out of you have to experience this, have to remove this crown because there's something broken or something wrong. You want to be able to access that screw. So by taking the crown oS, or whether you're cutting the crown oS, you still want to be able to access the top of that screw. So if you take oS this Teﬂon tape, you'll be able to access your screw and unscrew the abutment. All right. So that's what a cement retained the restoration look like. What is a screw retained restoration. You heard Fletcher say that earlier. Is that the only way we can restore an implant? The answer is no. So this is what I just showed you, right? The implant, the abutment, the screw that holds it into place, and then the Teﬂon tape. And then you just submit the crown on top of the abutment. Right. And it has the sealed margins. The second version is that part three. Part two are together already. And then this screw instead of just holding the abutment. So there's a hole in the middle of the crown as you see there. And this whole part, this whole assembly is one piece. So essentially the crown and the abutment are cemented outside. And then that whole thing is held in by one screw versus a screw just holding the abutment. And then the crown not having a hole and getting cemented on top of it. Does that make sense? I'll explain it one more time. So think of the cement retained restoration, just like a regular prep tooth. Number 30. You prepped it, you have a crown that's going to go on top of it, right? Your prep is the abutment that's held in by a screw. And then the crown that's being cemented on top of a screw retained is essentially a tooth that has no prep whatsoever. It's essentially, you know, you could just see the the, you know, pulp chamber, if you will. Okay. And your abutment and crown are one piece already. But the crown has a hole in it from the top. Because this whole crown and abutment assembly, instead of using any cement, will be held just by the screw. So some of you are asking. This seems easier. Why would I ever want to do this? This requires multiple steps. That requires cement. I could leave cement behind. There are restorative, um, scenarios where I need to use something cement retained. There are restorative scenarios that I need to use, stuS that is retained. There are sometimes issues that may arise that may not allow me to like, let's say like, when would that be? I don't know, restoring an interior tooth. And what if my screw access is on the like here at the incisal edge or on the facial? You can try to mask it and put a composite or put something up or plug that hole, but it won't look the same, right? Not to mention that. And we'll talk about this on a on a in a future lecture. There are anatomical limitations. Scrutin is one piece. That means it's only going to go in one direction. Right. Cement retained. I can put in the abutment. I can get a pre plated abutment here. Fleischer said that word this morning. So instead of the abutment looking in straight so let's say tooth number. 30. Is tipping measly. Okay. And tooth number 28 is tipping distally, right? Whatever. I did that the other way around, but they're tipping this way. Can I put a screw it in crown that goes in straight? I can't because the implant is also going to be tipped this way, right? So I'm going to have to use something that cement retained. So the abutment is going to correct the angulation. So my abutment instead of coming out this way my abutment will go in this way. But it will be angled kind of like if you were to prep the tooth and the tooth is tipped this way, you're going to you're not going to tip, your prep is going to correct the tipping. Right. So you're going to prep maybe a little bit more on the medial, a little less on the distal right. So the abutment is going to correct the angulation. And I can only place a cement retained crown. So each one of these and we're going to talk I'm going to show you cases about this to help you understand this better. When we talk about restoring the implant. But there are certain cases where this is the restoration of choice, and there are certain restorative, restorative scenarios where screw retained is this, uh, restoration of choice. All right. You saw this picture. Fleischer kind of glossed over or explained to you the diSerence between what an implant is and what natural tooth is. The biggest thing is that. Really the forces. All right. And how the tooth responds to the forces and how the implant responds to forces. Right. I'm sure you've already heard about PDL. I'm sure Motoko talked to you about, like, you know, mouth occlusion and and how teeth adapt. Right? I just gave you the example of if you're biting into an olive or a date or something that has a pit in it and you accidentally hit the pit, your jaw automatically opens as a protective function, right? To protect your teeth from breaking and, you know, protect your teeth from moving into directions that they're not supposed to. Implants won't do that. They don't have that protective function. They'll just chomp on it because they don't know any better. All right. SPEAKER 8 So. SPEAKER 7 If you have forces that are not favorable, you'll see a restorative failure. And that's how you're going to ﬁnd out that something is wrong. The patient won't be like, oh yeah, no. When I bit like, it's sort of like glass shattering against each other or ceramic, you know, hitting each other. And until something gives, the patient won't know that something is wrong versus, you know, if you were to punch me or like, you know, hit me on my shoulder, I automatically feel it because I have sensation there. You don't have sensation with an implant. All right. The surrounding teeth will have, but essentially it's reverberating into bone. There is no oxygen. There is no PDL. All right, so when you have signs of overloading and forces, you're going to get PDL thickening mobility. Right. Where for sets. That's kind of how we ﬁnd out in natural dentition with implants you're automatically going to get a restorative failure. Screw loosening fracture prosthesis fracture, implant fracture. All right. That's a sign that something's going bad. So some of these or most of these are reversible. Some of these are not. All right. Um. So. Forces applied to dental implants. Right. So the idea or the goal is to treatment plan our implants so that we minimize the amount of stresses that are transferring. So how do we do that? There are some factors aSecting the load bearing capacity of an implant. Right. I'll go through these real quick. So if we look at the forces applied to implants. Mainly vertical and horizontal. Those are compressive forces, right? I'm sure you heard already from occlusion. Compressive forces are the forces we like. Those are the forces that are directed down the long axis of the tooth. Right? So if they go well down straight down the long axis of the tooth, they're very well tolerated. They're actually accommodated best. And if I have cortical bone like I do on my mandible, it's actually the strongest in compression. Right. And because it is compressive it, it compresses masses together. So I'm not worried about the abutment coming loose because it's pushing the abutment into the implant if anything. Right. So it pushes masses together. So compressive forces are good forces. What are bad forces. Tensile. They're pulling from each other. What is an example of tensile I don't know. Does anyone eat like starburst or sticky candy. That's a tensile force right. Because it's pulling away. So that's going to be pulling you know your your tooth out of the socket or the crown and the abutment out of the implant. Right. So that's not a good force. The other one is a shear or sliding. So if my implant isn't already, is that at an angle. And the force is coming at an angle. SPEAKER 8 Right. SPEAKER 7 It's going to cause a lot of damage. And cortical bone is weakest to accommodate forces. Right. So when would this happen? If the occlusion is oS? Right? So instead of us adjusting the occlusion properly and making sure that all the forces are down the long axis of the tooth, if the patient is grinding side to side and I have a unwanted exclusive contact, I'm creating shear forces. All right. So the second thing we were going to talk about was the shape and dimension of the implant. So, as Fleischer showed you in multiple pictures, there are so many diSerent shapes and sizes and you know, whether it's three millimeters, whether it's seven millimeters, how wide it is, how long it is. Right. So you know, there's now implants that are 2.2 not just three. Right. But when we're talking about, you know, typical implants, not many implants, we're talking about three all the way up to seven millimeters in width. Um, length can go from eight, although there's a lot of six and ﬁve millimeter implants as well. Uh, and you Fleischer showed you that short one, um, up to 15mm. And they even have implants that are way longer than 15 if you're placing zygomatic, uh, implants. So the idea is that there was the study and down here, um, that. An implant with a wider diameter is more favorable in reducing the stress distribution in surrounding the implants, and as the length of the surface area increases, suggested that the stress level for a given applied load is reduced longer because the implant is longer. So essentially the wider and the longer the implant, the less forces you're going to have. Right now. Again, this wasn't done in patients, but it's sort of conceptually it makes sense, right? The wider you have something, the more load distribution, because it's not just on a three millimeter implant, but rather a 5 or 6 millimeter implant. What's very important when you read these studies, right? Because every company is going to try to tell you diSerently is whether they're looking at the implant or whether they're looking at the implant restored. Because the design of the restoration has just about every single determining factor on whether this is going to. So if I have an implant, think of a lollipop. You have a very skinny rod that you're holding the lollipop, but you have this big lollipop coming up. Right. The force is on the edge of the lollipop. Are very going to be very easy to chip that part of the lollipop versus the center of the lollipop, because that's where you're holding it. Right. So that design of the crown on the implant is going to determine whether it was a wider implant or whether it was a narrower implant, has nothing to do with the design of your crown. So be very, very critical when you read the read the literature. Does that make sense? So when they say white implant has a higher success rate based oS of what? The implant itself. Did they just do studies on implants with no restoration and they applied forces to them? Or was it the Crown itself that had the impact on the design? Did they standardize the size of the crown and use diSerent devices with implants? Am I making sense? So be very critical when you read this literature, right? So what is the advantage and disadvantage of using a wide diameter implant? Obviously an advantage is you're going to have a maximum amount of bone, you're going to distribute the stresses allows for application of higher torque limited. So problem with a disadvantage. And you're going to see this a lot is that you have limited space a lot of times okay I want to I'm restoring a molar. So I want a wider implant because I it's a bigger tooth right. But I don't have enough room okay. And esthetic requirements for a natural emergence proﬁle if I'm you know, so if we're saying a wider implant is always better, do I want to place a six millimeter wide implant to replace a lateral. No, because a lateral isn't even that wide. So it was going to it's not going to look nice at all. All right. Does implant length and width matter? Okay. So ultra wide implants. So they're even wider than six millimeters. So an excellent survival rate up to 90 almost 99%. Uh success rate. This other study, they looked at wide dental implants and they their follow up was up to 30 months. Um, and the implant diameter ranged from 5 to 6, with a survival rate of almost 98.5. This, uh, GriSin and Chung, they looked at eight six millimeters diameter and a millimeter long. The overall cumulative rate was 6 to 8 months. And essentially, they had a 100% survival rate. And again, we're going to talk a lot next week about survival versus success. So we're not going to get into that today because that's a two hour conversation. SPEAKER 8 Okay so how about length. SPEAKER 7 So these are this study looked at 13 diSerent studies. And they looked at almost 2000 implants. And 914 of them were short and a thousand of them were standard. The short dental implants had a survival rate of 88, and the standard had a lower standard, a lower survival rate. So does that mean a shorter, better or is longer better? No. Right. So don't be fooled. Right. Because companies will try to tell you, oh, our implants are the longest on the market. And because they're long, they're going to have a more surface area. Yeah, but over 2000 implants, it didn't matter. All right. So again, read the literature with a critical eye. So just say that you understand factors aSecting the success of of short dental implants, the the surface topography. So that was Fleisher was telling you about machined versus, you know, whether you saw the diSerence between SL and the SL active SLA and SL active, you know, that graph that Fleisher showed you that if it was chemically modiﬁed, it had a much higher osteo integration quicker. Within three weeks it was ready. Right. Um, what your surgical protocol is, what type of prosthesis are you doing? A single crown versus full arch. Are you splinting multiple restorations together?

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