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An Introduction

The Primary causes of complications in Implant Dentistry are related to Biomechanics( ) . Early Loading failures outnumber Surgical Healing Failures, especially in Soft bone When forces are Greater than usual or Implant sizes are shorter than 10mm.
to the study of Movement Application of Physics and Mechanics

Misch developed a treatment plan sequence to decrease the risk of Biomechanical overload, consisting of following-

Treatment Plan Sequence

Prosthesis Design.

Patient Force Factors.

Bone Density in the Edentulous sites. Key Implant Positions and Number. Implant Size. Available Bone in the Edentulous Sites. Implant Design.

The Incidence of Decay on a tooth Splinted In FPD generates 22% complications within 10 years. Individual crown have less than 1% risk of Decay with in 10 Years. Unrestored natural teeth have less risk of Decay. --- And As we Know --Implants Stand UNDECAYED!

A second complication of Teeth Supported FPD restoration is Endodontic related factors in 15% of cases with in 10 years. Implant abutments dont require Endodontic Procedures.

When an Implant restoration is joined to a Natural tooth an Increased risk of Abutment Screw loosening Implant Marginal bone loss and unretained restoration occurs. So The Ideal Treatment Plan isAn Independent Implant Restoration for Partially Edentulous Patient.

Key Implant Positions

Guidelines for Key Implant Positions. 1) No Cantilevers Cantilevers are force Magnifiers to the Implants, Abutment Screws, and Implant Bone Interface. Ideal Key Implant Position Include the Terminal abutment Positions when adjacent teeth are missing.

Fig 8-2

A cantilevered restoration on multiple Implants be compared with a Class 1 lever. Extension of the Prosthesis from the Last abutment is the Effort Arm of the lever. The Last abutment next to the cantilever acts as a fulcurum when a load is applied to the lever. The Distance between the last abutment and the farthest abutment from the end of the cantilever is Resistance arm or A-P spread of Implants.

Mechanical Advantage= The length of Cantilever(Effort arm)/Resistance arm =20/10=2. 25 lb force on Cantilever results 50 lb force on the farthest abutment from cantilever. Abutment closest to Cantilever receives force = Sum of (25+50 )lb force. Hence Proved Cantilevers Magnify forces to all the Abutments.

The Key Implant Positions when one or two adjacent

teeth are missing indicates one Implant per tooth .

A Three to Four unit Prosthesis may be fabricated with

only these abutments when force factors are low and the
bone density is favorable. Restorations of 5-14 units require additional abutments.

When the Implants are in one Plane ,the cantilever should

rarely extend farther than the A-P distance .

When force factors are unfavourable the cantilever length

should be reduced or eliminated, Implant number

increased ,implant size increased or the Implant design surface areas increased.

When five or more implants are positioned around

an arch and several different plains exist because of

the arch form of the splinted Implant the Cantilever may extend as far as 2.5 times the A-P distance when force factors are low and density is favourable . N.B More than two pontics are not Indicated on a Posterior Cantilever even
under Ideal conditions.

No Three Adjacent Pontics

In most Prosthesis designs three adjacent Pontics are contraindicated on Implants just as on natural Abutments Rationale: Adjacent abutments subjected to additional force when supported by 3 missing teeth. A one Pontic span exhibits little flexure 8 m or less under 25 lb load. A two pontic Span flexes 8 times more than a one Pontic span. And three pontic span flexes 27 times more than one Pontic Span.( Metal Flexure is related to cube of Distance).

In most Prosthesis design three adjacent Pontics are contraindicated on Implants just as on natural abutments . Rationale: Adjacent abutments subjected to additional force when supported by 3 missing teeth. A one Pontic span exhibits little flexure 8 micrometer or less under 25lb load. A two pontic span flexes 8 times more than a one pontic space.

No 3 adjacent Pontic
And three pontic span flexes 27 times more than one Metal flexure is related to Cube of distance.

Natural teeth Vs Implants

The Flexure of Materials in a long Span is more a problem for Implants than Natural teeth. As natural roots have mobility both Apically and laterally the tooth acts as Stress absorber and amount of material flexure may be reduced .

The Span of Pontics in the ideal treatment Plan is limited to the size of two Premolars which is 13.5-16mm. When a 2nd Premolar and first molar are missing treatment is Planned to replace three teeth rather than two. N.BA missing tooth span is often related to the missing number of roots in the mandible and number of buccal roots in the Maxilla.

This is more appropiate for greater Patient forces (moderate to severe parafunction) or softer bone types i.e (D a ) . An Edentulous Arch missing on 14 natural teeth may have 18 potential Implant size. When 4-14 missing adjacent teeth are to be replaced key Implant positions are located in the Terminal abutments and additional Pier or Intermediary abutments are indicated to limit the Pontic Spans to 2 premolar size Pontics or less.

5-7 premolar sized unit Prosthesis has 3 Key abutments ( 2 terminal and one Pier).

Canine and First Molar Sites

When the 1st premolar ,canine and lateral Incisors are missing key Implant positions are 1st Premolar and the canine. This results in a cantilever on the restoration Lateral Incisor is Smallest tooth. Anterior region has less bite force. Canine Implant is larger than a lateral incisor implant for meeting the esthetic requirement of the restoration.

In addition.
Occlusion is modified so that so that no occlusal contact is present on the lateral incisor Pontic in Centric occlusion or excursions of the mandible.

Schematic representation:A
When the Central ,Lateral Canine and First Premolar are missing the ideal key Implant positions are Central and First Premolar. Rule Followed: Rule 1 viz No Cantilever.

Schematic representation:B

When the Central ,lateral Canine, First Premolar,second Premolar and first molar are missing the three key Implant positions are the Central and 1st molar sites.( Rule 1). And the Canine site ( Rule 2 and 3, no 3 adjacent pontic and canine and first molar Position.

Schematic representation:C
When the central , lateral ,canine and first premolar and second premolar are missing there are three key Implant Positions: The Central and second premolar ( Rule 1: No cantilever and the canine position ( Rule 3 the Canine and 1st molar position.

Schematic representation:D
When 8 adjacent teeth are missing from second Premolar to opposite canine there are four key Implant positions : The canine and second Premolar position( Rule 1). The opposite canine ( Rule 3). One of central incisor positions (Rule 2).

Schematic representation:D
When 10 adjacent teeth are missing from second premolar to second Premolar there are five key Implant positions: The 2 second Premolar sites.(Rule 1) The 2 canine sites.( Rule 3) One of Central Incisor positions( Rule 2).

A traditional Fixed Prosthetic axiom

It is contraindicated to replace a canine and two or more adjacent teeth.

Implants are required when the following adjacent teeth are missing in either arch: 1st premolar, Canine and lateral incisor. 2nd premolar ,1st premolar and canine. Canine,lateral and Central Incisor. RATIONALE-

The length of the Span is 3 adjacent teeth. The lateral direction of force during mandibular excursion increase the stress. Magnitude of bite force is incresed in canine region as compared to anterior region. Therefore two key Implant positions required to replace three adjacent teeth usually in terminal position of span ( mainly when one of the terminal abutments is the canine.)

Schematic representation:A

When the patient is missing four teeth from the 1st premolar to second molar there are 3 key Implant positions to replace four teeth The 1st premolar and 2nd molar sites.( Rule 1) And the 1st Molar position ( Rule 3).

Schematic representation:B
When the Patient is missing 6 adjacent teeth from the Cito the first molar there are 3 Key Implant positions. The Central and 1st molar position.( Rule 1) And the canine position (Rule 3). When a larger Implant cannot be inserted in to the molar site an additional implant is required to follow Rule 2.

Schematic representation:C
When the patient is missing teeth from first molar to first molar there are five key Implant positions The two first molars( Rule 1) The two canines ( Rule 3) And a central Incisor (rule 2). Additional Implants in the posterior region are Indicated when larger diameter Implants is not positioned in the 1st molar sites.( Rule 2).

Implants in the second premolar sites are usually indicated when force factors are moderate or bone density is D. Even more Implant support is suggested when force factors are severe or bone density is D

Schematic representation:D

Key Arch Positions

When a patient is missing eight teeth from 1 st Premolar to 1st Premolar there are 5 key positions The 1st Premolar site ( Rule 1,no cantilever and Rule 4 One Implant in each open Pentagon segment. The two canines- Rule 3 the Canine and first molar rule and Rule 4 , an Implant in each Pentagon segment. And an Implant in one one of the CI position ( Rule 2, no three adjacent pontics . And rule 4, an Implant in each open pentagon segment.

When two or more segments of an arch are connected the tripod effect is Greater and as a benefit an A-P spread is created from the most distal terminal abutments to the Most anterior Pier abutment.

Implant should be positioned at least 1.5mm from an adjacent natural teeth and 3mm from an adjacent Implant, each 4mm diameter implant requires 7mm of mesiodistal space. Therefore maximum number of Implants between adjacent teeth can be calculated by taking the crest module of an Implant and adding these dimensions Minimum mesiodistal dimension for 2 standard 4mm diameter Implants is= 1.5mm+4mm+3mm+4mm+1.5mm=14mm.

Splinted Implants
Splinted Dental unit provide greater prosthesis retention and transfer less force to the cement interface as a result restoration is less likely to become uncemented. Specially when Abutments are short or lateral forces are present.

Why Splinted Implants are here to Stay!

A single crown has an endodontic risk of 3-5.6% Splinted teeth have an endodontic risk of 18% As Implants dont decay or need endodontic therapy hence indepent units would not be required to address these complications.

Splinted Implants increase functional surfsce area of support , increase the A-P distance ( A-P Spread) to resist lateral loads increase increase cement retention of the prosthesis. Decrese the risk of abutment screw loosening . Marginal bone loss. The risk of Implant component fracture.

In addition to biomechanical reasons if Independent Implants fail over time Implant is removed the site bone is grafted , the site is reimplanted and a new crown is fabricated . When multiple splinted Implants have an Implant that fails the affected Implant may be cut below the crown and the Implant or crown side is converted to Pontic.

A biomechanical based treatment plan reduces complications after Implant loading with the prosthesis. To reduce stress conditions there are key Implant positions for a prosthesis replacing missing teeth 1) No cantilevers should be ideally designed on the restoration. 2) 3 adjacent pontics should be eliminated. 3) The canine and first molar sites are important positions in an arch.

An arch is divided in to 5 segments when more than 1 segment of the arch is being replaced ,a key Implant position is atleast ONE Implant in each missing segment

Increasing the number of Implants is the most efficient method to increase surface area and to increase overall stress.Therefore after the key Implant positions are selected additional implants are indicated to reduce the risks of overload from patient force factors or Implant sites with reduced bone density.


Dr. Carl E. Misch(PhD).

Thank You!