Camlog Compendium 2 Prosthetics by camlog

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23.10.2007

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2 Prosthetics The CAMLOG Compendium, consisting of Part 1. Surgery and Part 2. Prosthetics, covers the whole spectrum of clinical and prosthetic practice from the practitioner's viewpoint (using more than 800 graphics). The CAMLOG Compendium is targeted at users in order to ensure the proper handling of the system. In prosthetics, CAMLOG stands for interdisciplinary teamwork - combining the skills of dentist and dental technician to develop implant solutions that benefit the patient.

â&#x17E;¤ The first part of the manual, Surgery, addresses insertion of the different CAMLOG implant geometries. It also contains a description of the CAMLOG concept in prosthetics, general system information, and prosthetics planning up to surgical intervention.

â&#x17E;¤ The second part, Prosthetics, opens up the multiplicity of CAMLOG implant treatment options that the dentist and dental technician can apply. The patented implant abutment connection allows natural-looking, implant-based perioprosthetics to provide both fixed and removable dentures.

Rest of World

The Americas

ISBN 3-13-134361-3 ISBN 978-3-13-134361-1

ISBN 1-58890-473-3 ISBN 978-1-58890-473-7

www.thieme.com

2 Prosthetics

The CAMLOG implant system is one of the most successful implant systems on the international market.

CAMLOG Compendium

2 Prosthetics

CAMLOG Compendium | 2 Prosthetics

CAMLOG 速 Compendium 2 Prosthetics All materials and dental procedures mentioned in this Compendium must be used and applied by qualified dentists and physicians only. The CAMLOG Compendium consists of two parts: 1 Surgery 2 Prosthetics Single pages must not be distributed.

Chapter Overview CAMLOG Compendium 1 Surgery: I. General system information II. CAMLOG concept III. Planning IV. Surgery manual CAMLOG Compendium 2 Prosthetics: V. Prosthetics Manual

CAMLOG Compendium | 2 Prosthetics

Bibliographic information of the German Library

The German Library catalogs this publication in the German National Bibliography; detailed bibliographic information can be found on the Internet at http://dnb.ddb.de.

All rights, including reprinting, reproduction in any form and translation into other languages, are reserved by the copyright holder and publisher. The manual may not be reproduced in whole or in part by photomechanical means (photocopy, microfiche) or stored, exploited systematically or distributed with electronic or mechanical systems without written approval from CAMLOG Biotechnologies.

Authors: Karl-Ludwig Ackermann, Axel Kirsch Alexander Focke, Dieter Mozer, Rainer Nagel, Gerhard Neuendorff, Alex SchĂ¤r, Bernd Wagner

Manufacturer: ALTATEC GmbH Maybachstrasse 5 71299 Wimsheim, Germany Copyright ÂŠ 2005 CAMLOG Biotechnologies AG Part no.: J8000.0028

Printed in Germany Cover design: CAMLOG Team, Thieme Verlagsgruppe Print/binding: Grammlich, Pliezhausen

Rest of World ISBN 3-13-134361-3 ISBN 978-3-13-134361-1

The Americas ISBN 1-58890-473-3 ISBN 978-1-58890-473-7

Important note: Like every field of science, medicine is undergoing continuous change. Research and clinical experience are continuously extending our knowledge, particularly of treatment and therapy with medications. Where this publication refers to a dosage or administration, the reader can be assured that the authors, editor and publisher have taken great care to ensure that this information conforms to the state of knowledge at the time of publication. However, the publisher cannot accept any liability for information on dosage instructions and forms of administration. Every user is urged to examine carefully and if necessary consult a physician or specialist on whether the recommended dosage and administration or the information on contra-indications in the package inserts of the preparations is different from the information given in this publication. It is particularly important to examine this in the case of preparations that are rarely used or those that have just been introduced to the market. Every dosage or administration is entirely at the user's own risk and responsibility. The authors and the publisher request all users to inform the publisher of any inaccuracies or discrepancies noticed. Protected brand names, trademarks or proprietary names are not specially indicated. The absence of such indication does not mean that it is not a trademarked or proprietary name. This publication, including all parts thereof, is protected by copyright. Any use, exploitation, or commercialization beyond the limits set by copyright legislation without the approval of CAMLOG Biotechnologies is not approved and subject to legal sanctions. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage.

CAMLOG Compendium | 2 Prosthetics

Contents

V. Prosthetics Manual

1. General information Notice . . . . . . . . . . . . Torque ratchet – Maintenance . . . . . . – Usage of the tools . . – Settings . . . . . . . . . 2. Planning General information Diagnostic cast . . . Planning template . Drill template . . . . .

. . . .

..................

.................. .................. ..................

2 2 2

. . . .

. 4 . 8 . 9 . 10

3. Transfer system Introduction . . . . . . . . . . Impression methods . . . . Impression material . . . . Closed impression method Open impression method . Registration . . . . . . . . . .

. . . . . .

11 11 11 12 15 18

4. Temporary restoration Introduction . . . . . . . . . . . . . . . . . . . Preparation of the temporary abutment Temporary crown/bridge . . . . . . . . . . Insertion . . . . . . . . . . . . . . . . . . . . .

. . . .

19 19 21 21

5. Preparation of work Introduction . . . . . . . . . . . . Cast fabrication – Closed impression method – Open impression method . Cast conditioning . . . . . . . . Articulation . . . . . . . . . . . . Wax-up/set-up . . . . . . . . . . Silicone index . . . . . . . . . .

. . . . . .

22 23 24 25 26 26

6. Abutments Introduction . . . . . . . . . Abutments . . . . . . . . . . Abutment selection . . . . Abutment selection aids

. . . .

27 27 28 29

. . . .

. . . . . . . . . . . . . . 22

CAMLOG Compendium | 2 Prosthetics

7. Single-tooth crown Introduction . . . . . . . . . . . . Abutment preparation – Ceramic abutment . . . . . . – Titanium abutment . . . . . . – Gold-plastic abutment . . . Crown fabrication . . . . . . . . – Casting . . . . . . . . . . . . . – Devestment . . . . . . . . . . – Cementable . . . . . . . . . . – Vertical screw-retention . . – Horizontal screw-retention – Splinted crowns/bridges . . Insertion . . . . . . . . . . . . . . – Abutments . . . . . . . . . . . – Cementation . . . . . . . . . . – Screw-retention, vertical . . – Screw-retention, horizontal

. . . . . . . . . . . . . . 30 . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

31 34 37 38 38 38 39 40 42 43 46 47 48 49 49

8. Removable constructions Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Set-up/tooth arrangement . . . . . . . . . . . . . . . . 50 9. Telescopic technique Introduction . . . . . . . . . . . . . . . . . . Transfer to the milling table . . . . . . . Cast fabrication for milling technique Abutment preparation Universal/telescopic abutment . . . . . Gold-plastic abutment . . . . . . . . . . . Secondary coping . . . . . . . . . . . . . . Tertiary framework . . . . . . . . . . . . . Set-up and try-in . . . . . . . . . . . . . . Finishing and insertion . . . . . . . . . .

. . . . . . . . 52 . . . . . . . . 52 . . . . . . . . 52 . . . . . .

. . . . . .

54 56 59 60 61 62

CAMLOG Compendium | 2 Prosthetics

10. Bar technique Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Custom-milled bar Introduction . . . . . . . . . . . . . . . . . System components and materials . Abutment selection . . . . . . . . . . . . Wax-up preparation . . . . . . . . . . . Bar wax-up . . . . . . . . . . . . . . . . . Casting and devestment . . . . . . . . Trimming . . . . . . . . . . . . . . . . . . . Try-in . . . . . . . . . . . . . . . . . . . . . Bonding the titanium base . . . . . . . Milling and finishing . . . . . . . . . . . Electroformed secondary framework Tertiary framework . . . . . . . . . . . . Bonding the electroformed secondary framework . . . . . . . . . . Bar finishing . . . . . . . . . . . . . . . . Set-up and try-in . . . . . . . . . . . . . Finishing . . . . . . . . . . . . . . . . . . . Insertion . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . .

64 64 65 66 67 68 69 70 70 72 73 74

. . . . .

75 76 76 76 77

Prefabricated bar Introduction . . . . . . . . . . . . . . . . . . Fabrication types . . . . . . . . . . . . . . System components and materials . . Impression and abutment selection . . Cast fabrication . . . . . . . . . . . . . . . Base for bar abutment, solderable . . System components and materials . . Base for bar abutment, laser-weldable System components and materials . . Base for bar abutment, cast-on . . . . System components and materials . . Base for bar abutment, burn-out . . . . System components and materials . . Bar try-in . . . . . . . . . . . . . . . . . . . Tertiary framework . . . . . . . . . . . . . Set-up and try-in . . . . . . . . . . . . . . Finishing and insertion . . . . . . . . . . Integration into an existing denture .

. . . . . . . . . . . . . . . . . .

78 78 79 80 81 82 82 84 84 85 85 87 87 89 89 89 89 89

CAMLOG Compendium | 2 Prosthetics

11. Ball abutment (Dalbo system) Introduction . . . . . . . . . . . . . . . . . . . System components and materials . . . Setting the retention force . . . . . . . . . Placing the ball abutment . . . . . . . . . Aligning the duplication components . Duplicating the working cast . . . . . . . Metal reinforcement . . . . . . . . . . . . . Bonding the matrices . . . . . . . . . . . . Set-up and try-in . . . . . . . . . . . . . . . Finishing . . . . . . . . . . . . . . . . . . . . . Insertion . . . . . . . . . . . . . . . . . . . . . Integration into existing denture . . . . . Indirect method (laboratory fabrication) Relining . . . . . . . . . . . . . . . . . . . . . Recall procedure . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

Information Information on instrument preparation Notice . . . . . . . . . . . . . . . . . . . . . . . Materials . . . . . . . . . . . . . . . . . . . . . Certificates . . . . . . . . . . . . . . . . . . .

. . . .

.100 .101 .102 .104

90 90 91 91 92 92 92 93 93 94 94 95 96 98 99

General information Notice FOR THE DENTIST AND DENTAL TECHNICIAN

V. Prosthetics Manual 1. General information Notice The cooperation between the dentist and dental technician is greatly simplified if the important data of the geometry of the implant used, the gingiva height, and the desired prosthetic configuration are noted on an information worksheet in the dental office and the worksheet accompanies the work. Because the form remains with the prosthetic work, every dental technician has the relevant information available immediately. This prevents time wasted answering obvious questions.

Dental Office/Laboratory Information Worksheet Date:

Patient Last Name: ________________________________________ First Name(s): ________________________________ Date of Birth: ______________________

Dental Office

Dental Laboratory Name Date

Type of treatment Buccal markers Abutment Implant diameter

Additional information is added to the worksheet in the laboratory and returned to the dental office with the finished work. This gives the dentist all the important information for placement.

Implant length Type of implant ✼ 1 ▲ 18 ▲ 48 ✼ 32

2 17

3 16

4 15

5 14

6 13

7 12

8 11

9 21

10 22

11 23

12 24

13 25

14 26

15 27

16 28

47 31

46 30

45 29

44 28

43 27

42 26

41 25

31 24

32 23

33 22

34 21

35 20

36 19

37 18

38 17

Type of implant

Because it is important that both the dentist and dental technician understand the CAMLOG system, it is recommended that the entire Prosthetics Manual be reviewed by all members of the implant team. For the convenience of the reviewer, individual sections are identified as • FOR THE DENTIST AND DENTAL TECHNICIAN • FOR THE DENTIST • FOR THE DENTAL TECHNICIAN. Pages identified as “FOR THE DENTIST AND DENTAL TECHNICIAN“ include either general information applicable to both the dentist and dental technician or subsections specific to both specialties.

Implant length Implant diameter Abutment Buccal markers Type of treatment Implant diameter: 3.3 / 3.8 / 4.3 / 5.0 / 6.0 mm Implant length: 9 / 11 / 13 / 16 mm, Type of treatment: ST* / bridge / telescopic / bar / ball abutment Implant type: SL = Screw Line / RL = Root Line / CL = Cylinder Line / SCL = Screw-Cylinder Line

Alloy / Solder: _______________________________________________________

Technician: _______________________________________________________

Ceramic: _____________________________________________________________

Final check / date: _______________________________________________

Acrylic: ______________________________________________________________

Patient ID / Date: ________________________________________________

Tooth shade: ________________________________________________________ ✼ ▲

USA numbering European numbering

General information Torque ratchet – maintenance FOR THE DENTIST AND DENTAL TECHNICIAN

Torque ratchet For final insertion all abutment prosthetic screws and abutments must be tightened to the specified torque with the torque ratchet.

Attention: Abutments must be retightened to the same torque after five minutes to reach the maximum retaining screw tension. This prevents screws from loosening.

Maintenance The torque ratchet must be disassembled into five separate components after use. Unscrew the torque adjustment screw (5) completely and pull spring (4) and handle (3) off. Pull the fastening pin back with thumb and forefinger and remove the ratchet wheel (1) from the ratchet head (2). Preclean the parts with a small

plastic brush under running water, then immerse in desinfectant solution (immersion time as specified by the manufacturer). Rinse thoroughly and dry. Wet the parts indicated with the red ▲ icon with contra-angle handpiece oil or spray and reassemble the torque ratchet. Insert the ratchet wheel (1) first: pull the

fastening pin back with thumb and forefinger and insert the ratchet wheel (1) at IN with the narrow side towards the ratchet head (2). Then slide the handle (3) on, push the spring (4) into the handle and turn the torque adjustment screw (5). Sterilize the ratchet in the autoclave before clinical use. (See “Cleaning and sterilization instructions”).

▲

The tools click into the ratchet wheel; to remove them press the handle (8) of the tool with a finger and remove from below. Do not use pliers.

▲

Inserting tools Screwing in: IN is visible (6), unscrewing: OUT is visible (7).

General Information Torque ratchet – adjustment FOR THE DENTIST AND DENTAL TECHNICIAN

Setting the torque limitation The selected torque (newton-centimetres) is set by screwing the torque adjustment screw in or out (9). The torque ratchet clicks out when the specified torque is reached (10). Do not continue beyond this point!

Torque settings for CAMLOG components Abutments must not be screwed tight with the torque ratchet in the laboratory. The following values are only relevant for clinical use. ATTENTION: Use new retaining screws for final placement to ensure optimum initial tightness.

Setting for the torque ratchet Implant cover screw Gingiva former Impression post

tightened by hand tightened by hand tightened by hand

Abutment/prosthetic screws – Provisional abutment – Ceramic abutment – Esthomic abutment – Standard abutment – Universal/telescopic abutment – Gold-plastic abutment – Horizontal screw – Prosthetic screw

tightened by hand 20 Ncm 20 Ncm 20 Ncm 20 Ncm 20 Ncm tightened by hand 15 Ncm

Abutments – Bar abutment – Ball abutment

Ø 3.3 mm: 20 Ncm 20 Ncm

Ø 3.8 – 6.0 mm: 30 Ncm 30 Ncm

Planning General Information FOR THE DENTIST AND DENTAL TECHNICIAN

The following general information is illustrated in Compendium 1 Surgery. Overview Every planning process is divided into the following sections: • Actual situation Specification and documentation of the actual situation by general medical history, special (dental) history, intraoral and extraoral clinical diagnosis, functional diagnosis and radiological diagnosis. Altogether this information provides a description of the initial status of the oral system. • Initial prosthetic situation An ultimate (maximum) treatment goal is defined from the diagnosis, the requirements, the desires of the patient for esthetics and function and from the wax-up and set-up. • Ultimate treatment goal A cost-benefit/work-benefit/risk-benefit analysis of the various treatment options is made with the patient. The final result will be a treatment goal customized for the desires and options of the patient. • Individual treatment goal Prosthetically oriented implant positions are defined and verified clinically and radiologically with reference to the individual treatment goal. Finally, the treatment sequence is defined. It includes the plans for accompanying measures, grafting and any required preliminary treatment.

Anamnesis Introduction The medical history and diagnosis are not different from the evaluation procedures required for other dental surgery or restorative treatments. For this reason only the specific points for perio-implant prosthetic treatments are described below. The general, social and special (dental) medical history considers all general medical contraindications and diseases that could affect the microcirculation or the patient’s suitability for the proposed implant-based restoration. Risk factors such as nicotine, alcohol and drug abuse are confidentially evaluated, discussed and documented. The patient’s psychological and psychosocial situation gives an indication of the compliance that can be expected and will influence the planning of the treatment and the future prosthesis design. General The general medical history should include not only the disease history but also regular medication usage and the possibility of general medical problems that could adversely affect an implantbased prosthetic treatment.

Special (dental) The special medical history must clarify the reasons for the current situation of the oral system. It may provide information on systemic diseases that may not have been detected yet. If implants or grafts were previously placed this may be important for assessment of the bone quality.

Planning General Information FOR THE DENTIST AND DENTAL TECHNICIAN

Diagnosis Clinical In addition to all standard extraoral findings, the soft-tissue profile or the support of the soft tissues (particularly in the maxilla) is a significant factor in designing the prosthesis. If a large discrepancy between the required labial tooth position and the expected position of the implant is found, this may require delivery of a removable denture for loading reasons (bar, telescopic crown, ball abutment). The intraoral diagnosis includes assessment of all teeth for whether they are worth retaining. In addition to the examination of the soft tissue for pathological findings, the care of the teeth is assessed for information on the patientâ&#x20AC;&#x2122;s possible compliance during and after treatment. The static and dynamic occlusion, interalveolar distance and jaw relations are checked. Diseases of the jaw joints must be treated before starting dental treatment. All findings that could indicate excess loading on the masticatory system (e.g. bruxism) must be investigated, documented and considered in the prosthetic planning. The status of the soft tissue in edentulous jaw sections (width and thickness of the attached gingiva) must be checked and the extension of the alveolar ridge must be evaluated for suitability as a possible implant site.

Dental x-rays Dental x-rays are sufficient for an initial assessment of the bone volume with single tooth gaps and small interdental gaps. The periodontic situation of the remaining teeth must be closely examined, because the implant site could be infected by pathogenic organisms from infected pockets. Panoramic x-ray An OPG is required to provide basic information. Depending on the situation, dental x-rays, remote x-ray side views or CAT scans provide additional information. Remote x-ray side view Use for large sagittal differences and planned bone removal in the chin region. CAT scan Three-dimensional imaging divided into individual slices. Cast analysis A diagnostic cast must be mounted in an adjustable articulator for assessment of the jaw relations. It is particularly important to check whether a change of the occlusal position is worthwhile or required. This should be done before starting the implant-prosthetic treatment if at all possible. A change of the vertical dimension must be preceded by treatment with a long-term provisional.

Articulation The diagnostic cast is placed in an adjustable articulator with the aid of an arbitrary face-bow register and a centric register as in perioprosthetics. Vertical dimension If the vertical dimension requires correction, it must be done by a guard or longterm provisional treatment before the implant-based prosthetic restoration. Jaw relationship (transversal) The jaw relationship affects the load direction and therefore the axial alignment of the implants. This is particularly important with cross-bite situations. Jaw relationship (sagittal) The crowns cannot be placed precisely over the implants in the case of an Angle class II dentition because the soft tissues must be supported and the space for the tongue must not be reduced. A removable denture is indicated in this situation. Initial prosthetic situation The initial prosthetic situation describes the dental status and the jaw relationship, the anatomical status of the oral hard tissue, the intraoral and extraoral soft tissue, the existing functional, phonetic and esthetic restrictions of the patient and the related influence on the patientâ&#x20AC;&#x2122;s quality of life.

Diagnostic casts The diagnostic casts must clearly show the occlusal surfaces, the vestibular fold and the retromolar regions.

Planning General Information FOR THE DENTIST AND DENTAL TECHNICIAN

Preliminary prosthetic design Introduction Modern implant prosthetics is planned by working back from the desired goal of the therapy; this is referred to as â&#x20AC;&#x153;backward planningâ&#x20AC;?. This is particularly important for pre-implant grafting measures intended to restore sufficient bone structures to allow placement of implants in the optimum prosthetic position. Forward planning, which is only oriented to anatomical-surgical conditions, is no longer used. Function, phonetics and hygiene capacity require prosthetically oriented implant positioning and dimensioning, which the dental technician defines on the basis of the wax-up. The prosthetic design and the required implant position(s) are planned by the dentist and the dental technician. This requires them to be fully informed of the treatment options. If an implant cannot be implemented for a fixed reconstruction for functional, esthetic or hygienic reasons, a removable solution must be planned.

Wax-up/set-up The wax-up or set-up is fabricated on the patient cast in the dental laboratory. The optimum tooth position from an esthetic and functional point of view can be planned in this way. The possible discrepancy between the atrophied jaw bone and the prosthetically required crown position allows a timely diagnosis of any required grafting measures. The ideal occlusion concept will be a cuspid dominated occlusion or cuspid disocclusion. Freedom in centric should be possible. Planning template A planning template is fabricated to test the planned implant positions in the mouth. The template can be converted to a surgical drill template later. Radio-opaque markers may be included depending on the CAT scan evaluation procedure (e.g. titanium, barium sulfate).

Planning General Information FOR THE DENTIST AND DENTAL TECHNICIAN

Verification of the implant positions Goal The goal is to specify the possible implant positions. Now the final implant planning is carried out according to the selected concept. The x-ray images must show calibrated measurement points to enable measurement of the bone volume available for implant placement. Clinical The wax-up or set-up must be tried in on the patient. It allows esthetic aspects to be included in the plan, such as the smile line, tooth color, facial shape and general presentation of the patient. CAT scan with/without 3D evaluation A precise three-dimensional evaluation of the bone contour is only possible with a CAT scan. Simulation programs can be used for computer-aided evaluation. Special findings such as septums or infections in planned sinus-floor elevations and critical vertical relationships in the mandible can be recognized. Depending on the program the template should include radio-opaque position markers (titanium balls, titanium tubes, barium sulfate coating).

Orthopantomograph X-ray foils in various scales are available for all implant geometries for checking the dimensions in the OPG. The magnifications of the foils correspond to the magnification factors of most OPGs, but they are only useful as approximations for implant dimensioning. Final prosthesis design The surgical feasibility of the treatment sequence is checked with reference to the clinical situation, the casts and the x-ray findings. Depending on the clinical situation, periodontic and grafting treatment is conducted before the implant surgery or at the same time as the implant placement. Documentation for patient interview and information The results of the planning are discussed with the patient. Casts, x-ray images and the planning devices (wax-up and setup) are helpful here. The following criteria are considered.

Individual adaptation of the prosthesis design The patient’s wishes regarding the scope and cost of the implant-prosthetic restoration expressed in the patient interview are incorporated into the individual prosthesis design. The number of implants, the requirement for grafts and possible soft-tissue corrections are determined exclusively from the local findings and the prosthetic design. This interview must be documented in detail and the patient must sign a statement of consent before implementing the treatment process. Planning the treatment sequence When the prosthetic goal has been defined, the required treatment steps are specified in a backward planning process. This process must include all details that are likely to be found, particularly in connection with grafting. The planning template can now be converted into a surgical template.

• Initial situation • Desires and expectations regarding esthetics, function and comfort • Cost/benefit ratio • Costs • Risk

Dental x-ray A metal ball with a known diameter (> 4 mm) can be included in the x-ray of the planned implant position to check the dimensions.

• Duration of treatment • Restrictions in comfort during treatment

Planning Diagnostic cast FOR THE DENTIST AND DENTAL TECHNICIAN

2. Planning Diagnostic cast The diagnostic casts for implant-prosthetic planning should be fabricated from superhard stone, similar to perioprosthetics, and mounted in an adjustable articulator with an arbitrary face-bow and centric occlusion register. The centric occlusion must be clearly indexed to allow the casts to be mounted with correct axial alignment and correct position. The impression must reproduce the softtissue condition and any condition in hard and soft tissue defects to include the vestibular fold, because this is where the first indications of a required inclination of the implant or grafting can be identified. As in perio-prosthetics, the retromolar regions must also be reproduced to allow specification of the dental arch and assessment of the vertical volume (see arrows).

The use of templates greatly simplifies the planning and implementation of a peri-implant prosthetic rehabilitation. Planning template Planning the best possible restoration by wax-up/set-up requires an adjustable articulator. Bone deficits should not be considered at this stage. The template may be used to fabricate a silicone index during fabrication of the prosthesis. X-ray template The planning template developed from the ideal wax-up/set-up should include CT tubes or other radio-opaque markers positioned at the ideal implant site.

The CT information derived from the x-ray template can be used to determine the bone volume and quality with the aid of a CT and a 3D evaluation. This will determine the subsequent therapy procedure (number of implants, implant position, implant diameter and implant length). The final prosthetic design and the hard and soft tissue grafting, if required, are discussed with the patient on the basis of this information and approved. Drill template The planned implant positions are tried in and compared with the x-ray information and adjusted if necessary. The adjustments change the x-ray template into a drill template.

Planning Planning template FOR THE DENTIST AND DENTAL TECHNICIAN

Planning template The dental technician fabricates a complete wax-up/set-up with all missing teeth in their ideal prosthetic position. In accordance with the â&#x20AC;&#x153;backward planningâ&#x20AC;? principle anatomical deficits are not considered at this stage. The treatment goal determines the surgical and prosthetic procedure. A silicone index is fabricated from this set-up. After setting, the index is divided orally along the central occlusion line to form a labial and an oral section similar to a denture plate. An acrylic template can be fabricated with the aid of the silicone index. Alternatively the work can be done with a rigid vacuum form foil via a duplicate cast.

Planning Drill template FOR THE DENTIST AND DENTAL TECHNICIAN

To control the planned implant positions on x-rays, markers can be integrated into the template if required. Titanium tubes for CT-supported planning or other radio-opaque positioning components (barium sulfate) are integrated, depending on the software used for evaluation. If the tubes are placed directly at the soft tissue level, its thickness can be detected on the CT. For more information see the documentation for the systems.

Drill template The positions of the titanium tubes are modified or specified in the template. In consultation with the surgeon the template is reduced to a framework to enable stable positioning during surgery. After preparation of the flap, stability requires a dental or gingival base outside the planned surgical region.

Transfer system Introduction FOR THE DENTIST AND DENTAL TECHNICIAN

3. Transfer system Introduction The parts of the transfer system are titanium and are manufactured by CNC milling technology. This provides an extremely precise, rotationally stable transfer system for closed and open impression methods. The system components are color-coded according to the implant diameter. Note that only implant and prosthetic components of one diameter (color-coded) may be used together. Components of different diameters must never be connected to one other. The system components must not be modified.

Impression methods The closed or open impression method may be selected (1). The open impression method should be selected if the abutments axis are diverting or used in combination with a functional impression (2). Special impression posts, which are described in the applicable chapter, are used with the prefabricated bar.

Impression material Hydrocolloids and silicone or polyether can be used as impression materials for the closed method. Silicone or polyether materials are recommended for the open impression method.

Color-coding

Ø 3.3 mm

gray

Ø 3.8 mm

yellow

Ø 4.3 mm

red

Ø 5.0 mm

blue

Ø 6.0 mm

green

Transfer system Closed impression method FOR THE DENTIST

Closed impression method

System components The system components for the closed impression method are all color-coded (10). The impression post (3) comes with the retaining screw (4), impression aid (6) and bite registration cap (5). The transfer impression cap and the bite registration cap (5) are single-use articles. The hex screwdriver, short or long (1+2), is used. The retaining screw (4) is tightened manually in the implant and in the lab analog (7).

Bite registration cap

5 Transfer cap

3 6 4 Impression post Lab analog Retaining screw

1 7 2 Hex screwdriver, short, long

ATTENTION: Transfer caps and bite registration caps are single-use articles. Do not reuse these parts!

When the impression post is inserted, the retaining screw extends about 2 mm.

When the screw is seated, it is flush with the top. (4 â&#x20AC;&#x201C; 5 revolutions).

10 Overview of color-coded impression posts and impression aids

Transfer system Closed impression method FOR THE DENTIST

Placement of the impression post After removal of the gingiva former or the temporary abutment, the impression post with the retaining screw is inserted into the implant (12). Tactile engagement of the cams with the implant grooves can be detected when the post is rotated (13). ATTENTION: The retaining screw extends about 2 mm (15). The post is rotationally symmetrical, making a particular alignment unnecessary.

The retaining screw is tightened manually (15 â&#x20AC;&#x201C; 17) with the hex screwdriver (if necessary use x-ray images to check that the impression post is correctly seated). 11

Transfer system Closed impression method FOR THE DENTIST

Impression The color-coded impression cap is placed on the impression post using the guide grooves (16) until it passes a perceptible pressure point and the impression cap is fixed in place (17). Three guide grooves on the impression post (at 120째 intervals) allow the impression cap to be positioned without contacting adjacent impression caps or teeth (18). The extensions on the impression caps must not be removed. Check that the impression cap is correctly seated immediately before taking the impression (19). The impression caps remain in the impression after removing the tray. If this is not the case, the impression must be repeated.

TIP: We recommend sending the lab analog to the laboratory to enable fast fabrication of the cast. The implant diameters are noted on the worksheet. Send the impression post screwed to the lab analog to prevent loss of the retaining screw (19).

III 18 Three possible positions of the impression cap

Transfer system Open impression method FOR THE DENTIST

Impression A customized impression tray is required for the open impression method. The tray must be perforated at the extension of the implant axis for the retaining screws on the impression posts. System components The system components for the open impression method are color-coded (5). The retaining screw is secured by an O-ring (2+3). The retaining screw is hand-tightened only in the implant and in the lab analog (1).

Before removing the impression (4) the loosened screw must be pulled back to the stop (O-ring) (2), otherwise it may not be possible to remove the impression because of the off-axis inclination of the implants or the impression may be deformed by excessive compression.

5 Overview of color-coded impression posts

Transfer system Open impression method FOR THE DENTIST

Placement of the impression post The gingiva former or the temporary restoration is removed. Before placement of the impression post the screw is pushed fully in apical direction to orient it in the direction of the implant axis (6+7). The impression post for the open impression is placed in the implant and the retaining screw is screwed in lightly (9). The impression post is rotationally symmetrical, making a particular alignment unnecessary. The post is pressed on to the implant and rotated until the cams click into the grooves of the implant (10).

7 6

ATTENTION: Height difference is only 0.4 mm (9).

10 The retaining screw is tightened manually with the screwdriver. The correct seating of the impression post may be checked by x-ray (10+11).

Transfer system Open impression method FOR THE DENTIST

Impression After checking the perforations (13) and the dimensions of the customized impression tray, the impression can be taken with elastomeric (silicone or polyether) material (14).

To remove the impression loosen the retaining screw, pull it back completely and then remove the impression tray (15+16). TIP: We recommend sending the lab analog to the laboratory to enable fast fabrication of the cast. The implant diameters are noted on the worksheet.

Transfer system Registration FOR THE DENTIST

System components For bite registration the impression posts for closed impression are used (3+10) (see Closed Impression Method). The appropriate color-coded bite registration caps (5) are placed on the impression posts (8). The correct seating is indicated by an audible click (9). The caps do not contain sharp edges. A registration can be made with the standard registration materials. The bite caps must not adhere to the registration and are also sent to the laboratory (11).

3 6 4 1 7 2

If the vertical dimensions are unsuitable and a bite registration is not taken, cylindrical 6 mm gingiva formers can be used as an alternative. ATTENTION: Note the diameter, position and height of the gingiva former in the worksheet and deliver a corresponding gingiva former with it.

Transfer caps and bite registration caps are single-use articles. To retain precision they must be used once only.

Temporary restoration Preparation of the temporary abutment FOR THE DENTIST AND DENTAL TECHNICIAN

4. Temporary restoration Introduction The PEEK temporary abutment (3) (PEEK = PolyEther Ether Ketone) is designed for esthetic immediate restoration or for long-term temporary restoration. The advantage of immediate implant placement with an esthetic, non-functional immediate restoration is that the structures of the periodontal or periimplant tissue are supported, particularly in esthetically critical regions. After a sufficient healing phase (osseointegration) for the implant and the periimplant soft tissue, another impression is taken for the final restoration.

1 4 System components Temporary abutments PEEK (3) are available for all implant diameters except 3.3 mm. The abutment screw (5) is screwed in manually with the hex screwdriver (1+2). The retaining screw (5) is supplied with the abutment.

7 6

Preparation of the temporary abutment The abutment is inserted into the implant and rotated until the cams audibly click into the grooves (6+7). Then the retaining screw is inserted and tightened manually. The preparation margin is marked on the abutment corresponding to the gingiva line (8). 8

Temporary restoration Preparation of the temporary abutment FOR THE DENTIST AND DENTAL TECHNICIAN

The temporary abutment is prepared outside the mouth. It can be held with the universal holder for preparing abutments or a lab analog for easier handling (10). A preparation is made as in perio-prosthetics following the marking (9) that corresponds to the gingival contour (10). The most suitable preparation tools are high speed diamond burrs, without water cooling and low pressure. The chamfer or crown margin should be placed in a paragingival position for an esthetic immediate restoration and 1-1.5 mm subgingivally with delayed restoration to achieve an anatomical emergence profile of the peri-implant

An impression is taken with the transfer system immediately after placement or uncovery of the implant to facilitate a temporary restoration in the laboratory. After fabrication of the master cast the abutment is prepared in accordance with the anatomical requirements and the temporary crown is fabricated (12+13). Fabrication in the laboratory allows metal reinforcement to be used if necessary (for long span bridges), similar to a long-term temporary denture.

tissue. A mark (13) is placed on the labial side of the abutment for easier recognition of the insertion position.

Temporary restoration Temporary crown/bridge FOR THE DENTIST AND DENTAL TECHNICIAN

Temporary crown/bridge A pre-fabricated crown or an existing crown is adapted by lining it with acrylic and molded to the situation (14). The insertion direction of the crown, determined by the neighboring teeth, and the direction of the screw canal in the implant rarely match. For this reason the abutment and the crown are fabricated in separate units. The trimming is done outside the patientâ&#x20AC;&#x2122;s mouth. All other procedures for fabrication of temporary restorations are also possible in the same manner as crown and bridge prosthetics.

Insertion of the temporary restoration The prosthetic components must be cleaned and desinfected before insertion. The implant is sprayed inside with water to remove any residue and blown dry. The temporary abutment is inserted into the implant and rotated until the cams audibly click into the grooves of the implant (15). After carefully handtightening the abutment screw, the screw cavity is filled with soft acrylic (16). Do not use composite, because it has to be drilled out to gain access to the screw (17). The crown will only fit if the screw channel is not overfilled. Remove any excess cement completely.

Literature Sofortimplantation und Sofortbelastung. Das Einzelzahn-Sofortimplantat mit provisorischer Versorgung. Nagel, Rainer; Ackermann, Karl-Ludwig; Kirsch, Axel ZMK 17, 1 â&#x20AC;&#x201C; 2 / 2000

Preparation of work Cast fabrication FOR THE DENTAL TECHNICIAN

5. Preparation of work

System components Apart from the impression posts supplied by the dental office, only a hex screwdriver (1) and the lab analogs matching the diameter (2) are required for cast fabrication. Information from the dental office is included on a completed worksheet.

Introduction All prosthetic components used in the laboratory are hand-tightened. The abutments and abutment retaining screws are made of Ti6Al14V alloy (for material data see appendix). WARNING: Do not modify the implantabutment connection (tube, cam) under any circumstances.

Closed impression method The impression post (1) is screwed manually into the lab analog of the appropriate diameter (2+3) (4â&#x20AC;&#x201C;7). After checking that it is seated correctly without a gap (7) it is carefully positioned in the impression tray with the impression cap (8). It is important to make sure that it fits into the grooves in the impression cap (9). Do not use glue.

Master cast The impression is first conditioned and disinfected as specified by the manufacturer of the material. If milling work is planned (telescopic crowns, bars), two casts may be required.

1 3 2

The master cast is fabricated (10) (11) by the standard procedure. When filling the impression with stone by vibration make sure that none of the impression posts are loosened. Articulation immediately follows the model fabrication. The color-coded cap for bite registration is pushed on until it audibly clicks into place.

10 22

Preparation of work Open impression method FOR THE DENTAL TECHNICIAN

Open impression method The impression post is hand-tightened to the color-coded lab analog. Make sure that it is correctly seated with no gap (1 â&#x20AC;&#x201C; 4).

Then the master cast is fabricated in the standard procedure (5). To remove the impression the retaining screw must be loosened and pulled back completely (6). The master model is based in accordance with the system in use (7).

Articulation The impression posts for the closed impression method are mounted with the bite registration cap or the corresponding gingiva former depending on the selected method (8). The casts are articulated in the open impression method by using standard registration techniques.

8 23

Preparation of work Cast conditioning FOR THE DENTAL TECHNICIAN

System components Cast condition by smoothing the plaster cast above the lab analog shoulder is recommended for placement of the abutment (6) without interference. The profiler of the correct diameter is used to widen the plaster cast (1). The profiler is centered by a guide pin (2). In its final position the profiler sits on the guide pin. This prevents damage to the lab analog.

4 After removal of the impression post (5) the color-coded guide pin (7) is screwed in hand-tight. Then the profiler with the matching diameter (1) mounted in the universal holder (3) is slid on to the guide pin (2) and rotated clockwise into the cast (8+9). When the reamer is fully inserted, it is in contact with the guide pin (10). The profile frees the lab analog shoulder to ensure a correct emergence profile and the abutment is seated without a gap (11).

1 2

Preparation of work Cast conditioning FOR THE DENTAL TECHNICIAN

The plaster dust must be removed completely before removing the guide pin (12).

A small notch can be cut into the lingual/palatal side of the model (14) for a visual check that the abutment fits exactly into place (13).

Articulation The impression posts for the closed impression method are mounted with the cap for bite registration or the corresponding gingiva former depending on the selected registration (15). The casts are articulated in the open impression method by using standard registration techniques.

Preparation of work Wax-up/set-up FOR THE DENTIST AND DENTAL TECHNICIAN

Wax-up/set-up A silicone index makes it much easier to gain an overview of the space available for the prosthetics. It is fabricated from a wax-up/set-up without abutments (1+2). This procedure makes it quick and easy to check the dimensions of the restoration during subsequent stages of the work. It can be used for all restorative options (4).

3 Silicone index After try in of the shape, axis and esthetics on the patient, a silicone index (3) is fabricated based on the wax-up / set-up. The index must cover the dental arches from oral to labial. After setting of the material the index is cut lingually to the incisal or occlusal center line. This gives an overview of the shape of the crown after removal of the set-up, i.e. a guide for the required preparation of the implant abutment (4).

Abutments Introduction FOR THE DENTIST AND DENTAL TECHNICIAN

6. Abutments Introduction The high precision and stability of the CAMLOG implant/abutment connection facilitates standard crown and bridge laboratory techniques. The dental technician selects and prepares the implant abutment. Abutments The following abutments are available in the CAMLOG system:

1 Ceramic abutment 2 Esthomic abutment with anatomically shaped shoulder, straight and angled (20°), gingiva height 1.5 and 4 mm

15º 15º

3 Standard abutment with straight shoulder, straight and angled (15°), gingiva height 1.5 and 4 mm 4 Universal/telescopic abutment 5 Inset abutment, gingiva height 1.5 mm, with anatomically shaped shoulder. The shoulder diameter corresponds to the implant diameter. 6 Gold-plastic abutment, cast on All abutments must be adapted to the individual situation.

20º 20º

2 27

Abutments Abutment selection FOR THE DENTIST AND DENTAL TECHNICIAN

Abutment selection The suitable abutment can be selected with the aid of an index. The following information is important for the abutment selection: implant axis, gingiva height, cam position (for angled abutments), vertical dimension to the occlusal level. 1. Implant axis (1): Up to approx. 10Â° axial inclination can be compensated with a straight abutment. If the axial inclination is greater, angled abutments or the gold-plastic abutment must be used.

2. Gingiva height (2): The selection criterion is the maximum interproximal thickness of the gingiva/papilla. The specified gingiva height corresponds to the height at the lowest labial point. Because the final crown margin must be 1 â&#x20AC;&#x201C; 1.5 mm subgingival on the labial side and paragingival at the lingual/palatal side, an abutment with an appropriate gingiva height must be selected (3+4) to enable preparation of an esthetic, hygienic crown margin.

Abutments Abutment selection aids FOR THE DENTIST AND DENTAL TECHNICIAN

3. Vertical dimension to the occlusion level (5): The implant lenght indicated on the worksheet determines the implant (I L) crown (C L) ratio. This indicates the necessity for splinting the crowns. The ideal ratio is < 0.8.

5 4. The inset abutment (6) may be used where space is particularly restricted. The special feature of this abutment is that its maximum diameter is equal to the implant diameter. A cast-on gold-plastic abutment is available as an alternative to titanium abutments. The cast-on abutment can also be used for fabrication of a vertical (occlusal) screw-retained crown. 6

The color-coded abutment selection aids (7) simplify selection of the final abutments. They match the geometry of the Esthomic and standard abutments. An abutment that fits the axial inclination and gingiva margin is selected on the master cast. The selection aids can be used more than once. They have only one cam and are completely colored to distinguish them from the clinical abutments. They must not be used in the patient's mouth under any circumstances. 7

Single-tooth crown Abutment preparation FOR THE DENTIST AND DENTAL TECHNICIAN

7. Single-tooth crown Introduction The components of the CAMLOG system allow fabrication of single-tooth crowns according to standard perio-prosthetic protocols. Implants with a diameter of 3.3 mm should be used as lower incisors or upper lateral incisors only. If the ratio of the crown length to the implant length (see worksheet for implant information) is greater than 0.8, the implant crown must be connected to the neighboring prosthetics. The following abutments are available: 1 Ceramic abutment 2 Esthomic abutment 3 Standard abutment 4 Universal/telescopic abutment 5 Inset abutment 6 Gold-plastic abutment The crowns can be fabricated for cement or screw-retention. The preparation information is included with the relevant abutment type.

Single-tooth crown Abutment preparation FOR THE DENTAL TECHNICIAN

Ceramic abutment 2 Introduction The ceramic abutment consists of a titanium base (1), a zirconium oxide sleeve (2) and an abutment screw (3). Zirconium oxide is an extremely strong and hard material. Its advantages are: 1. Precisely milled titanium base with the CAMLOG tube-in-tube connection. 2. With the subsequent bonding of the titanium base and separately customized

2 4 1

1 3 zirconium oxide sleeve the abutment can be modified or colored with ceramic compounds* without any thermal influence on the implant/abutment connection in the cervical area. 3. Screw head seats in metal part.

* Use only ceramic compounds with a suitable Coefficient of Thermal Expansion (CTE) (10.5 â&#x20AC;&#x201C; 11.0).

Preparation For customization of the zirconium oxide sleeve (2) a universal handle (5) with two separate holders for grinding the sleeve (8â&#x20AC;&#x201C;10) , one for the diameters 3.3 mm, 3.8 mm, 4.3 mm (6), one for 5.0 mm and 6.0 mm (7) are available.

6 2

10 31

Single-tooth crown Abutment preparation FOR THE DENTAL TECHNICIAN

The titanium base is inserted into the lab analog in the model, the rotation lock points in the lingual/palatal direction (11) (maximum wall thickness towards the labial side) and the base is hand-tightened with the abutment screw (12). Then the zirconium oxide sleeve is positioned over the base and rotated until the rotation lock clicks into place (13). The abutment height is marked on the zirconium oxide sleeve with the silicone index in place. The shoulder margin must be 1 â&#x20AC;&#x201C; 1.5 mm subgingivally on the labial side and paragingivally on the oral side (15+16). Preparation of the zirconium sleeve The zirconium oxide sleeve is placed on the holder of the appropriate diameter (6+7) for grinding of the zirconium oxide sleeve and rotated until the rotation lock clicks into place. The zirconium oxide sleeve is locked with the clamping screw (10). Grinding is conducted with diamonds with a geometry similar to tooth preparation (17). Use standard grain size and fine for finishing. Water irrigation to prevent cracking/furrowing by local overheating is essential. The wall thickness must not be less than 0.5 mm. The abutment should be prepared with an angle of approx. 3Â° and a shoulder width of 0.5 mm.

17 32

Single-tooth crown Abutment preparation FOR THE DENTAL TECHNICIAN

Bonding the zirconium sleeve to the titanium base The bonding surfaces of the zirconium oxide sleeve and the titanium base are grit-blasted with 50 Âľm aluminum oxide at max. 2.0 bar (psi). Then the bonding surfaces are cleaned with alcohol or steam (to remove dust and grease) (18). We recommend attaching the titanium base to a lab analog or polishing aid for ease of handling during the bonding process. The hex head of the abutment screw must be covered with wax.

The bonding agent (such as Panavia F 2.0) is mixed as specified by the manufacturer and applied on the titanium base (19). The prepared zirconium oxide sleeve is pushed on to the stop (20). Make sure that the rotation and position lock clicks into place. Remove large cement residue immediately. The air blocker (Oxygard) is used at the ceramic/titanium transition area and in the screw hole to harden the bond (21). The residue is removed with a rubber polisher after bonding is complete (22+23). The porcelain crown is fabricated following the manufacturerâ&#x20AC;&#x2122;s directions.

Single-tooth crown Abutment preparation FOR THE DENTAL TECHNICIAN

Titanium abutment Introduction A universal handle (1) with abutment holders color-coded to match the diameters (2) is available to simplify preparation of the titanium abutment (3). The holder (2) is attached to the handle (1) with a clamping screw (hex) and the abutment is fixed in place with the retaining screw (4).

4 5

2 4 The following sequences show the preparation of the abutment in the posterior mandible and in the anterior maxilla.

An abutment is selected by checking the size with the silicone index (6 â&#x20AC;&#x201C; 9).

2 Clamping screw (hex)

8 34

Single-tooth crown Abutment preparation FOR THE DENTAL TECHNICIAN

Preparation The desired contour of the preparation margin (labially 1 – 1.5 mm subgingival, lingually: gingival level), the height and axial alignment are marked (permanent marker) with the assistance of the silicone index (10+11).

10 The abutment is fitted in the universal holder for easier handling. The coarse preparation can be made with an emery paper roll or a carbide bur for titanum (coarse cut) (12+13). The maximum speed is 10,000 rpm. Work with low pressure to avoid overheating the titanium. First the height

and axial inclination are adjusted, then the preparation is made the same way as a standard chamfer preparation of a tooth (preparation angle 2 – 4° (depending on length), crown margin 1 – 1.5 mm subgingival labially, lingual/palatal at gingival level). The fine preparation and finishing of the chamfer

11 are made with titanium burs (fine cut) (14+15). Do not allow the material to overheat. During preparation the abutment may be returned to the cast and every phase of grinding can be checked with the silicone index.

Do not overheat the titanium, otherwise the surface will harden unevenly. This “alpha case” layer greatly reduces the options for further modification.

15 35

Single-tooth crown Abutment preparation FOR THE DENTAL TECHNICIAN

To make subsequent insertion of the crown easier, the preparation cross-section (18+19) should not be completely circular but preferably oval or triangular â&#x20AC;&#x201C; similar to the root cross section of the natural teeth (16+17) â&#x20AC;&#x201C; and must have a milled tapered guide groove.

Mandible

Maxilla

Titanium abutment The finished customized abutments are tried with the silicone index to ensure that there is sufficient space for the subsequent crown and bridge restoration. Always use the maximum length for a large retention area (20+21). The abutment surface must be conditioned in proportion to the retention area immediately before final cementation. 20

Insertion to the mouth is greatly simplified by the labial side mark (22+23) on the abutment. This is particularly helpful with multiple abutments. Note the type of marks on the worksheet.

TIP: The abutments are marked on the labial side (flat trough[s]) to allow orientation during placement. The mark is recorded on the worksheet.

Single-tooth crown Abutment preparation FOR THE DENTAL TECHNICIAN

Gold-plastic abutment Introduction The gold-plastic abutment (1) consists of a cast-on base (Cerunor) and a burnout plastic sleeve. Unlike the titanium or ceramic abutments, the anatomical form is achieved by wax-up and then casting. Note: The cast-on base (tube connection) must never be modified.

The gold-plastic abutment can be used to fabricate transocclusal screw-retained single-tooth crowns and primary crowns for the telescopic technique. The gold-plastic abutments are not color-coded.

Preparation The abutment is fixed manually to the lab analog with the retaining screw (2+3). The plastic sleeve is shortened and checked against the silicone index (4+5).

Then the desired shape is waxed-up (6+7). The metal abutment shoulder must not be completely covered with wax. The wax-metal transition must be checked under magnification to make sure that it is gap-free.

Single-tooth crown Crown fabrication FOR THE DENTAL TECHNICIAN

A metal margin approx. 0.3 mm wide must be left at the implant-abutment transition, which must be free from grease and wax (8+9). This will prevent the fused material (casting vapor) from overshooting on to the base surface of the abutment.

Casting Make sure that the wax coping is correctly positioned in the casting ring during investing (10). The metal tube must not be positioned too close to the ring walls or floor, otherwise it will lose heat (cooling rib). If the tube cools too quickly the casting may be faulty. The preheat temperature of the casting ring must be increased approx. 50 째C. 10

Devestment The prefabricated CAMLOG connection of the gold-plastic abutment must not be mechanically altered or damaged under any circumstances. Residues of the investment compound can be cleaned off with acid or steam. We recommend fixing the abutment to a lab analog for finishing and polishing.

Single-tooth crown Crown fabrication FOR THE DENTAL TECHNICIAN

Crown fabrication Cemented Before building-up the wax/acrylic coping, the building-up thread of the optional horizontal screw-retention and the screw canal are closed (1+2). TIP: Apply a thin film of lubricant to the abutment to make it easier to lift the coping (Vaseline or similar).

The crown framework is fabricated on the prepared abutment similar to the standard crown and bridge technique (3+4). This applies for function, esthetics and hygiene. A metal island should be created, lingual/palatal, to allow for the grip of a detachment instrument (5). To allow removal of the implant crown at a later time, a slight undercut is made supragingivally in the framework island to provide a grip for a crown remover (6+7).

Insertion to the mouth is greatly simplified by a mark on the labial side of the abutment. This is particularly helpful with multiple abutments. Note the type of mark on the worksheet.

Single-tooth crown Crown fabrication FOR THE DENTAL TECHNICIAN

Vertical screw-retention A single-tooth crown with vertical/occlusal screw-retention can be fabricated with cast-on gold-plastic abutments.

The gold-plastic abutment is fixed to the lab analog with the retaining screw (1) and the plastic sleeve is shortened to 1.5 – 2 mm below the occlusion level (2) (check with silicone index).

3 The framework must be shaped identically to the tooth, but smaller (3) to obtain an even ceramic layer. The minimum metal thickness of the cast-on

alloy in the cast area must be 0.3 mm after trimming (4). Note the CTE of Cerunor (CTE: 12.5/20 °C – 500 °C) to prevent tension cracking.

4 40

Single-tooth crown Crown fabrication FOR THE DENTAL TECHNICIAN

The framework around the screw channel must not be trimmed too thin or left with sharp edges. Complications may arise during ceramic veneering (cracking/scaling) (6+7). 7

After completion of the metal core (9) veneer it with standard ceramics (10).

Single-tooth crown Crown fabrication FOR THE DENTAL TECHNICIAN

Screw position

Horizontal screw-retention Esthomic line

Ø 1.4 mm: 3 5

Screw position

0.030”

2 Standard line

6 If horizontal screw-retention is planned, the implant alignment (one groove facing labially) must be aligned precisely during implant placement. The screw direction is defined by the implant position and the abutment selected from the Standard or Esthomic range (6 – 8). The cast-on screw sleeve (4) can be integrated into the wax-up for horizontal screw retention. The screw (3) must be hand-tightened only. The screw must not be modified, otherwise the contact surface of the hex will be lost. For all horizontal screw retentions note that the anatomical shape of the crown in the oral region must not be negatively influenced by the position of the screw (check with the silicone index) (1+2).

Customized horizontal screw retention can be done by using the universal telescopic abutment or the gold-plastic abutment. When defining the screw axis, make sure that the screw can be easily inserted intraorally.

Insertion to the mouth is greatly simplified by a mark on the labial side of the abutment. This is particularly helpful with multiple abutments. Note the type of mark on the worksheet.

Single-tooth crown Crown fabrication FOR THE DENTAL TECHNICIAN

Splinted crowns/bridges Introduction If the ratio of crown length (C L) to implant length (I L) (1) (see worksheet for implant information) is greater than 1, the neighboring single-tooth crowns should be splinted after consultation with the dentist. Bridges are best fabricated in several small units. A free-end cantilever is not permitted on a single-tooth crown. With splinted crowns or bridges a freeend cantilever must not exceed the size of a premolar.

The implant abutments must not be primarily splinted. Implants with a diameter of 3.3 mm must be used as lower incisors or upper lateral incisors only. 2 The common insertion path (2) must be done by grinding or wax-up of the abutments. The abutments are hand-tightened to the lab analog with the retaining screw (3), the volume is appropriately reduced (check with silicone index). Then the gingival contour is marked to define the crown margin.

3 The adjustable table is placed in the parallelometer (milling unit) to set the common insertion path of the splinted crown or bridge. The common insertion direction can be prepared on the master cast, on the universal or on the customized milling table.

The insertion path must not be changed by modifying the implantabutment connection (e.g. shortening the tube).

Preparation on the master cast The abutment is prepared in the universal handle and the insertion direction is checked on the master cast in the parallelometer (milling unit) (4). Note the contour of the preparation margin (1.0 â&#x20AC;&#x201C; 1.5 mm subgingival). 4

Single-tooth crown Crown fabrication FOR THE DENTAL TECHNICIAN

Transfer to a customized milling table An additional set of lab analogs and impression posts, open tray, is required for preparation of the customized milling table. The impression posts for the open tray are mounted on the master cast (1). The posts are connected in the retentive area (NOT to the retaining screw) with a transfer construction (2) (cold-cured pattern resin). After loosening the retaining screws and retracting them completely, the connected transfer part with the impression posts is removed from the cast (3).

The corresponding lab analogs are screwed to the impression posts (4), then inserted into a milling table in superhard stone (5). The common insertion direction previously determined on the master cast is also the milling axis (7).

6 7

Single-tooth crown Crown fabrication FOR THE DENTAL TECHNICIAN

The selected titanium abutments are prepared for the common insertion path with a suitable titanium milling instrument (8+9).

The splinted crowns/bridges are fabricated with standard crown and bridge techniques (10 â&#x20AC;&#x201C; 12). The framework should be tried-in. The hygiene design is particularly important.

Single-tooth crown Insertion FOR THE DENTIST

Delivery Introduction The marking on the labial side of the abutment that is noted on the worksheet indicates the only possible position in the implant and ensures a quick and secure placement. The marking reduces the three possibilities of the abutment to one correct position, because it would have to be rotated 120Â° to the next position. Therefore a laboratory-fabricated insertion index is not required to find the correct abutment position.

System components The following instruments must be disinfected and prepared for insertion of the abutment in the patientâ&#x20AC;&#x2122;s mouth (follow hygiene procedures): 1 Hex screwdriver, short, long 2 Hex screwdriver, ISO shaft, short, long 3 Torque ratchet

(These components are included in the prosthetic set)

Preparation of the prosthetic components The prosthetic components must be disinfected before insertion. The implant is sprayed inside with water to remove any residue and blown dry. The peri-implant hard and soft tissue situation must allow a gap-free insertion of the abutment.

Single-tooth crown Insertion FOR THE DENTIST

Abutment insertion For insertion the abutment marking (6) is aligned labially and the abutment tube is inserted into the implant (7). When the cam is felt to be seated on the implant shoulder, the abutment is rotated until the cam is felt to click into the groove (8+9). The abutment moves 1.2 mm deeper into the implant.

6 7

Use new retaining screws for final placement to ensure optimum initial tightness.

The abutment screw is tightened with the torque ratchet to 20 Ncm (10). After about 5 minutes it must be retightened to 20 Ncm (see instructions for torque ratchet).

After tightening the abutment screw the opening is sealed to a concave channel (11+12). A convex excess must be avoided, otherwise a correct crown position cannot be guaranteed.

Single-tooth crown Insertion FOR THE DENTIST

Cementation Bite control index A bite control index can be fabricated to check that the crowns are correctly seated. It is made of light-cured acrylic (1+2). 2

Technique Before cementation, the abutment and crown are cleaned and dried by the standard method. Permanent phosphate or carboxylate cements are recommended for cementing. NOTE: It is important that the precise abutment-crown fit provides only a small cementation gap. Apply a thin coat of cement to the cervical margin of the crown only (approx. 1 mm) and position it (3+4).

Full ceramic crowns Full ceramic crowns are conditioned and cemented or bonded as directed by the manufacturer of the ceramic material (5).

ATTENTION: Carefully remove excess cement and clean the sulcus with dental floss or an interdental brush.

Advantages Cementing offers the following advantages during fabrication, insertion and recall: • Simple, similar to conventional crown and bridge technique • Time-saving, economical • Stable, large retention area • Esthetic, anatomical crown shape • Tight, between abutment and crown • Easy to maintain, short recall time

Single-tooth crown Insertion FOR THE DENTIST

Screw-retention Vertical (1) The crown fabricated with the gold-plastic abutment is placed on the implant. Make sure that the cam locks into place. The retaining screw is inserted and hand or machine tightened with the hex screwdriver. The screw is then tightened with the torque ratchet to 20 Ncm. After about 5 minutes the retaining screw must be retightened to 20 Ncm (see instructions for torque ratchet). After tightening the retaining screw the screw channel is sealed.

Horizontal (2) After inserting the abutment the restoration is placed, the horizontal screw(s) is/are screwed in and hand-tightened carefully. Do not overtighten the screw. Note: The hex 0.03â&#x20AC;? screwdriver is required for horizontal screwretention.

Removable constructions Set-up/tooth set-up FOR THE DENTIST AND DENTAL TECHNICIAN

8. Removable constructions Introduction At least six implants are required in the maxilla for removable superstructures, at least four in the mandible. When using implants 3.3 mm in diameter the prosthesis must be designed to ensure that extensions do not cause overloading. Tension-free seating of a secondary (telescopic) or primary (bar) splinted construction on implants is referred to as “passive fit”. With telescopic constructions this is achieved by intraoral bonding of the secondary copings (e.g. electroformed coping) to a tertiary framework. With bar constructions this is achieved by using crown sleeves for passive fit and intraoral bonding of the titanium base to the bar. In each case the goal is to fit the construction without tension.

Tip: Abutments or gingiva formers may be used to support a temporary denture base of cold-cured acrylic (1– 6).

Set-up/tooth arrangement The phonetic and esthetic anterior tooth arrangement of the denture must be done on the patient with the dental technician present. This procedure takes the individual situation and the patient's wishes into account at the earliest possible stage and ensures that the subsequent procedures are directed to that goal.

When planning a removable construction the implants should be placed to enable a fixed restoration to be added later, if required.

Removable constructions Set-up/tooth arrangement FOR THE DENTIST AND DENTAL TECHNICIAN

The anterior teeth are set up first on the stabilized denture base as specified in the planning stage (7+8).

After the phonetic and esthetic try-in on the patient (together with the dental technician), the posterior region is built up with a wax mold for a new bite registration (9+10).

After new articulation the set-up is completed (11+12). A silicone matrix is fabricated on the master cast from the wax set-up (13+14). The teeth are fixed to the matrix with sticky wax in the region of the future retaining elements (15). This makes it easy to check the available space and the maximum size of the abutment in every phase of fabrication.

Telescopic technique Cast fabrication for milling technique FOR THE DENTAL TECHNICIAN

9. Telescopic technique Introduction The rotational stability of the CAMLOG connection and the precision manufacturing make the CAMLOG system ideally suited for fabrication of telescopic prostheses. Two different methods are used for fabricating the secondary copings: 1. Cast copings similar to the wellknown telescopic crown technique with friction retention. 2. Electroformed copings with adhesive retention. The tension-free seating of the superstructure is very important for the longterm success of an implant-based restoration. All secondary copings must be bonded intraorally into the tertiary framework.

Transfer to the milling table The impression posts for the open tray (2) are mounted on the master cast (1). The posts are connected in the retentive area (NOT to the retaining screw) with a transfer construction (3+4) (cold-cured pattern resin).

Cast fabrication for milling technique The prosthesis can be fabricated on a second cast, on the master cast with a milling table or on the master cast with a removable gingiva mask. This decision must be made when starting the fabrication. We recommend determining the correct insertion direction for the patient under clinical conditions at this time. In some cases it will be necessary to incline the primary crowns in the labial direction.

Second cast • Cast two silicone/polyether impressions • Two impressions are required with hydrocolloids • Fabricate two casts • Specify insertion direction • Mill

Master cast and milling table • Specify insertion direction • Transfer implant position and insertion direction to the milling table • Mill

Master cast with removable gingiva mask • Immediate decision • Fabricate gingiva mask • Specify insertion direction • Mill

Telescopic technique Cast fabrication for milling technique FOR THE DENTAL TECHNICIAN

After loosening (5) the retaining screws and retracting them completely, the transfer construction with the impression posts is removed from the cast (6).

Lab analogs are screwed to the impression posts (7+8) (do not use polishing aids because there is no rotation lock) and mounted into a milling table oriented 0Â° (9 â&#x20AC;&#x201C; 10). Universal telescopic abutments or cast-on gold-plastic abutments are used as the primary components. 7

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Telescopic technique Abutment preparation FOR THE DENTAL TECHNICIAN

Universal/telescopic abutment Preparation The universal abutments (1) are placed in the lab analogs (2) and hand tightend with the abutment screws. The height and the axial alignment (3) are marked using the silicone index (4).

First the height is adjusted. To ensure sufficient retention the height of the functional area must not be less than 5 mm circular. After defining the insertion direction, fabrication is continued in accordance with the previously selected fabrication procedure: â&#x20AC;˘ Milling on the master cast (3) â&#x20AC;˘ Milling on the milling table (5)

Telescopic technique Abutment preparation FOR THE DENTAL TECHNICIAN

A taper angle of 2 – 4° is recommended for the electroplating technique, depending on the number of abutments and the available functional surfaces (6) (long abutments: 4°). Cast secondary crowns are prepared similarly to the standard telescopic crown technique. The butt-joint runs from supragingival to no greater than gingival level (7). The secondary coping is prevented from rotation by precision grooves. A sandpaper roller can be used for coarse preparation. It must be run at a maximal speed of 10,000 rpm and it should be applied at a low pressure only to prevent overheating the titanium.

First the axial inclination is adjusted, then preparation is continued similar to the standard chamfer preparation of a tooth. Titanium burs are used for fine preparation and shaping the shoulder. Do not allow the material to overheat.

Do not overheat the titanium, otherwise the surface will harden unevenly. This “alpha case” layer greatly reduces the options for further processing.

The surfaces must be homogenous (rubber polished) for fabrication of the secondary coping – high luster polishing is not required.

The space for the tertiary framework required to receive the secondary crowns can be tested at every phase of preparation with the silicone index with the denture teeth in position (8+9).

Telescopic technique Abutment preparation FOR THE DENTAL TECHNICIAN

Gold-plastic abutment Material data The gold-plastic abutment consists of a cast-on gold alloy (Cerunor)* and a pressed-on, burn-out plastic sleeve. The gold-plastic abutments are not colorcoded. 1

* Properties see Information Section Composition: Au 60% Pt 19% Pd 20% Ir 1% Metallic weight of basic parts: Ø 3.3 mm 0.57 g Ø 3.8 mm 0.65 g Ø 4.3 mm 0.83 g Ø 5.0 mm 0.91 g Ø 6.0 mm 0.99 g Melting range: 1400 – 1490 °C 2552 – 2714 °F

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Preparation The gold-plastic abutments (2) are placed on the cast into the lab analogs and hand tightend with the retaining screws (3). The silicone index is used to assist with marking the required length on the plastic sleeve to which it must be shortened (4 – 6). To ensure sufficient retention the height of the functional area must not be less than 5 mm circular. After defining the insertion direction (4) fabrication is continued in accordance with the previously selected fabrication procedure:

Telescopic technique Abutment preparation FOR THE DENTAL TECHNICIAN

Waxing The primary crowns are fabricated with the gold-plastic abutment similarly to the conventional telescopic crown technique. For the wax-up (1) note that the cervical margin of the gold-plastic abutment must not be completely covered with wax (2). A metal margin approx. 0.3 mm wide must be left on the goldplastic abutment. It must be free of grease and wax. This will prevent caston metal from overflowing on to the base area of the gold-plastic abutment as a result of expansion of the investment compound. The contour of the shoulder (1) should run from supragingival to gingival level. The minimum height of the primary components must be 5 mm circular.

Placing and investing The metal tube of the gold-plastic abutment must be aligned towards the heat center (3), because if the metal tube is cooled too fast the casting may be faulty. Use only phosphate-based investment compounds. Use only high precious metal alloys for cast-on procedure.

Devestment After cooling to room temperature the cast object is devested without mechanical impact. The precise CAMLOG connection of the gold-plastic abutment must not be mechanically processed under any circumstances. The investment compound residue on the cast object must be removed with acid or steam only.

TIP: The preheat temperature of the casting ring must be increased to approx. 50 째C. 3

Telescopic technique Abutment preparation FOR THE DENTAL TECHNICIAN

Preparation Preparation is continued by following the selected fabrication procedure (milling technique) (4 â&#x20AC;&#x201C; 7).

The penetration area through the gingiva is given a concave shape (8).

Telescopic technique Secondary coping FOR THE DENTIST AND DENTAL TECHNICIAN

Secondary coping Introduction It is very important for the superstructure to be seated without tension to ensure the long-term success of an implant-based restoration. Therefore, all secondary copings should be bonded into the tertiary framework intraorally. This also ensures that the denture is sufficiently stable. The minimum gap (5 µm) of the electroformed coping provides capillary spaces for the saliva and results in adhesion. The cast coping is retained by friction.

Electroformed copings Before electroforming the abutments are screwed to a lab analog (1). The lab analogs can be placed in acrylic (2). All parts that are not to be electroformed must be isolated (green area) and covered (2). Titanium surfaces can be directly electroformed (1). The casted abutments (3) must be isolated initially (green area) and then coated with conductive lacquer (blue area) in the relevant area (4). The electroforming (5 – 7) is continued as directed by the manufacturer. The layer must be 0.2 – 0.3 mm thick. The special feature of the low layer thickness of the electroformed components and the resulting low stability of the secondary coping prevent direct polymerization in the acrylic denture base and therefore a tertiary framework is necessary. Cast secondary coping The wall thickness of the secondary coping is guided by the minimum possible thickness allowed by casting technology (0.3 – 0.5 mm). Fabrication is similar to standard crown and bridge technique.

Advantages: • Purity (24 carat) • Homogeneity • Best possible fit • Reproducible precision • Easy to repair

Titanium abutment

Precious alloy abutment TIP: When removing the electroformed coping from the abutment for the first time carefully grip the lab analog with pliers and tap on lightly with an instrument.

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Telescopic technique Tertiary framework FOR THE DENTIST AND DENTAL TECHNICIAN

Tertiary framework Waxing A metal framework is essential for stabilizing the acrylic base and securely retaining the secondary coping. To fabricate the tertiary framework the working cast is blocked out, the coping is waxed over (1) (0.3 mm for bonding gap) and then duplicated (2).

The tertiary framework is built in wax on the duplicate cast with the silicone index as a control (3 â&#x20AC;&#x201C; 5).

The cervical margin of the secondary coping must be completely reproduced in metal (6+7). The tertiary framework can be fabricated from titanium or non precious alloy. The subsequent steps for complete fixation of the secondary components are done in the patientâ&#x20AC;&#x2122;s mouth.

Telescopic technique Set-up and try-in FOR THE DENTIST

Bonding of the secondary coping The secondary coping is fixed to the tertiary framework intraorally with a suitable metal bonding material. The abutments (primary crowns) prepared by the dental technician are placed in the cleaned implants and the retaining screw is hand-tightened. The secondary coping is prepared with a stone or diamond to improve the adhesion of the bonding agent and placed on the abutments. Then the tertiary framework is placed and the fit is checked for the secondary coping to ensure that it is seated securely and with an even cement gap (1). This ensures that the coping can be bonded later into the framework without tension (passive fit) (2 â&#x20AC;&#x201C; 4). After try-in, the bonding surfaces are grit-blasted and cleaned. Undercuts can also be made at this time. Follow the manufacturerâ&#x20AC;&#x2122;s instructions for bonding.

4 Tip: Spread a light coat of Vaseline on the abutments (primary crowns) before placing the electroformed secondary copings; do not coat the cervical margin.

Set-up and try-in After the metal bonding material has set, the framework can be removed from the mouth with the secondary coping bonded in without tension. The abutments are removed and sent to the dental laboratory for finishing the secondary coping/abutment transition. If the bonded tertiary framework cannot be replaced on the master cast without tension, the interfering abutment is removed from the master cast for further procedures.

The bonded points are trimmed (removal of excess material), the construction is coated with a denture-colored opaque layer to improve the cosmetic appearance (optional) and the teeth are positioned with the silicone index (5). The try-in is also used to check the phonetics, chewing function and esthetics, as with standard prosthetic procedures.

Telescopic technique Finishing and insertion FOR THE DENTIST AND DENTAL TECHNICIAN

DENTAL TECHNICIAN: Finishing The acrylic can be finished with heatcured or cold-cured material. Occlusion and articulation are adjusted in accordance with the functional requirements for centric and anterior/canine guidance. The occlusion and articulation are oriented to fixed restorations. The multipoint contact in centric occlusion and anterior/canine guidance guarantee long-term harmonization of the prostheses. The finished work can finally be inserted into the patient’s mouth after polishing the acrylic components.

Literature The Dental Cripple – oder Die wiedergewonnene Lebensqualität. Neuendorff G, Ackermann KL, Kirsch A, Hahn, C; dental spectrum, V, 2/2000, 91 – 114 62

1 DENTIST: Insertion The abutment marking is aligned labially and the abutment tube is inserted into the implant. When the cam is felt to be seated on the implant shoulder, the abutment is rotated until the cam is felt to click into the groove of the implant. The abutment will move 1.2 mm deeper into the implant. The retaining screw is inserted and tightend manually or mechanically with the hex screwdriver. The screw is then tightened to 20 Ncm with the torque ratchet (1). After about 5 minutes it must be retightened to 20 Ncm (see instructions

for torque ratchet). After tightening the abutment screw, the screw channel is sealed. Use new abutment screws for final placement to ensure optimum initial tightness. Then the prosthesis is inserted (2+3). Tip: When sealing the screw channel in the abutments (primary components) ensure that the final surface is concave. All acrylic residue must be removed to ensure that the prosthesis is perfectly seated (3).

Bar technique Introduction FOR THE DENTIST AND DENTAL TECHNICIAN

10. Bar technique Introduction Copings are available for fabrication of custom-milled or prefabricated bar constructions.

Passive fit Application of the passive-fit technique requires use of the burn-out bar sleeve for passive fit. Intraoral bonding of the titanium bonding bases (2) into the customized bar compensates for any imprecision (1) that could cause tension. 1

Custom-milled bar (3) Features: • Customized, hygiene-compatible shape • Parallel milled • One-piece cast • Passive fit

Prefabricated bar (4) Features: • Time-saving and economical with prefabricated components • Bar profile can be selected • Bar clip can be selected

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Bar technique Custom-milled bar FOR THE DENTIST AND DENTAL TECHNICIAN

Custommilled bar

Introduction Prefabricated bar components are available for bar technique with a custommodeled, milled bar. This makes it possible to adjust the bar position to the clinical situation as desired (below the

denture teeth) from a hygienic, functional and esthetic viewpoint. Special bar components for passive fit technique allow the bar to be adjusted without tension with no soldering or laser-welding. 10 a

10 b

6 System components and materials 1 Implant driver 3.3 â&#x20AC;&#x201C; 4.3 mm 2 Implant driver 5.0 and 6.0 mm 3 Screwdriver, 0.05 hex, short 4 Screwdriver, 0.05 hex, long 5 Ring wrench 6 Torque ratchet

7 8 9 10 a

Bar abutment Base for bar abutment, burn-out Base for bar abutment, cast-on Bar sleeve for titanium bonding base, burn-out 10 b Titanium bonding base for bar abutment 11 Prosthetic screw

Ti6Al4V Polyoxymethylene CERUNOR Polyoxymethylene Ti6Al4V

Diameters and gingiva heights Bar abutments are available in diameters of 3.3 mm, 3.8 mm, 4.3 mm, 5.0 mm und 6.0 mm (12). The gingiva height is the distance from the shoulder of the implant to the highest point of the surrounding gingiva. The bar abutment plateau should be about 0.5 mm supragingival. Abutments are available in heights of 0.5 mm, 2.0 mm and 4.0 mm (13).

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