IMPLANTOLOGY PART-II
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Classification of Implant According to Leonard. R.Rubin Classified according to the tissue into which they are embedded or on which they rest: Intraosseous implants: Receiving primary support from within bone Subperiosteal implants: resting on the bone beneath the periosteum Transosseous implants: stabilized by penetrating through both cortical plates Transcanal: support from an implant placed through the tooth root canal into the bone beyond the apex ď Ž
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According to Charles. A.Babbush There are five main types: • Mucosal Inserts • Subperiosteal Implants • Endodontic Implants • Endosseous Implants • Transosteal Implants According to Dennis C. Smith, David.F.Williams • Buried: Metals Non-Metals Metals: Magnets placed in the superior aspect of the body of the mandible and another set placed in the lower denture
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Intraosseous or Endosseous Type Implants
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Intraosseous or Endosseous Type Implants
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Subperiosteal type of implants
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Transosseous or transosteol type of implants
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Mucosal Inserts type implants
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Transcanal or Endodontic Type Implants
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Endodontic Stabilizers: Metal rods cemented into root canal of a natural tooth and extends beyond apex into the bone Non-metals: In ridge augmentation and facial recountouring procedures using proplast, ceramics and plastics Also in ridge maintenance efforts by placing implants made of carbon into recent extraction site root sockets • Semi-Buried: All true dental implants fall into this category Metals: Cobalt, Chromium, Molybdenum Non-metals: Ceramics, Bioglass, Carbons, Plastics www.indiandentalacademy.com
Classification of Implant Biomaterials
According to Charles A.Babbush, Carl. E. Misch • Metals and Alloys • Ceramics and Carbon • Synthetic Polymers and Composites Metals and Alloys: Titanium Co-Cr-Mo based alloy Iron-Chromium-Nickel based alloy Other metals www.indiandentalacademy.com
Tantalum Platinum Iridium Gold Palladium Zirconium Hafnium Tungsten
Ceramics: Bioactive and Biodegradable Ceramics based on Calcium Phosphates Metallic Oxide Ceramics: Aluminium Oxides Trocalcium Phosphates www.indiandentalacademy.com
Calcium
Aluminates Zirconium Oxide (Zirconia) Titanium Oxide (Titania) Synthetic Crystalline Structures like Hydroxyapatite Carbons : Pyrolytic carbon Polycrystalline Vitreous Carbon Carbon-Silicone interstitial combination Synthetic Polymers: Polyethylene Terepthalate (PET) Polymethyl Methacrylate (PMMA) www.indiandentalacademy.com
Ultra-high
Molecular weight polyethylene (UHMW-PE) Polypropylene Polysulfone Polydimethyl siloxane or silicone rubber Polytetrafluoro ethylene Composites: Bioresorbable polymers like Polyvinyl alcohol Polyacids or glycosides Cyanoacrylate www.indiandentalacademy.com
SURGICAL PROCEDURES IN IMPLANTOLOGY
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Stage I Surgery Also known as fixture installation stage, is the procedure for installing Branemark system implants into bone. This procedure demands exacting, non-traumatic preparation of the recipient site and a specific insertion protocol. Variations in this procedure mainly depends on the quality and quantity of bone and also on the load demands on the final prosthesis www.indiandentalacademy.com
Operatory: sterilized, ventilated, monitoring, resuscitation equipments etc
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All instruments including bone filters on suction, electrosurgical equipment, fine-toothed forceps etc
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Electrical delivery system: console, motor, handpiece, burs LED , provision for 2 motors, signal reverse direction
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Disposable plastic sleeve for motor and cord. Avoids repeated autoclaving
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Straight and contra-angle handpiece required
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Reduction gear angled handpiece system uses both internal and external irrigation
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High speed hand piece geared up to run at high torque with a speed of 1500 to 2000 RPMs, and the slow speed hand piece at high torque with speed of approximately 15 to 20 RPMs
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Drills used for bone preparation include: guide drill, 2 mm twist drill, pilot drill, the 3 mm twist drill, and countersink
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Irrigation unit is used to deliver an even, steady flow of sterile water to the surgical site at all times during high and low speed preparation
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Surgical guide stent is placed in the area to project the future position of the fixture
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Guide drill is the first drill used in the bone preparation process. It is designed to penetrate the cortical layer of the bone
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Initial penetration using surgical guide stent, is initiated using high speed guide drill at 1500 RPM. Copious saline irrigation used at all times
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2 mm twist drill is used second in the sequence to prepare the site to 2mm in diameter
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Site is progressively enlarged to 2mm with a 2mm twist drill at 1500 RPM
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Pilot drill is used next. Inferior portion of the drill is to engage the 2mm prepared site and superior portion begins the enlargement of the site
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Final orientation and inclination of the fixture is by using the pilot drill at high speed, high torque. It has an 2mm non-cutting edge and a 3mm cutting edge
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3 mm twist drill is fourth drill in bone preparation. Its used to prepare bone to its final destination
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Implant site is prepared to final length and width utilizing a 3mm twist drill operating at high speed
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Countersink is the final drill used in the high speed drilling process. It is used to create a shelf in the prepared bony site
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Crestal bone carefully prepared using countersink. Allows superior aspect of fixture to be placed crestally or sub-crestally, to avoid premature loading of the fixture during stage I healing
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Bone tap is the first in the series of slow speed bone preparation. Made of titanium and used to thread the bone prior to implant placement
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Receptor site is tapped utilizing a titanium tap operating at 15 to 20 RPMs along with copious irrigation
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Fixtures are composed of commercially pure titanium and range in length from 7 to 20 mm and width of range 3.75 and 4.0 mm
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Fixture mount is connected to the fixture
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Connection to handpiece is used to connect the fixture mount to the handpiece
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Fixture is connected to the handpiece, and inserted to the pretapped site at 15 to 20 RPMs
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Fixture is in position with connection t handpiece still connected
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Cylinder wrench used for final tightening of fixture
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Open end wrench to stabilize the fixture during removal of fixture mount
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Machine screwdriver used to unscrew the fixture mount from fixture
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Subcrestal position of the fixture
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Screwdriver, either hexagonal or slotted used to place cover screw into fixture
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Cover screws are available either a hexagonal or slotted configuration
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Coverscrew picked up in slow handpiece and placed into the fixture
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Appearance of fixture after insertion of cover screw
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Sutures placed
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Osseointegration Osseointegration implies that “it is a contact established without interposition of non bony tissue between normal remodeled bone and an implant at the light microscopic level, entailing a sustained transfer and distribution of load from the implant to and within the bone tissue". (Strock & Branemark 1939) Osseointegration was defined as “a direct anchorage to an implant body; which can provide a foundation to support a prosthesis. It has ability to transmit occlusal forces directly to bone� (Branemark 1983) www.indiandentalacademy.com
Osseointegration can also be defined as “a direct structural and functional connection between ordered, living bone and the surface of a load carrying implant” (Branemark 1985) “Osseointegration is an apparent direct connection of an implant surface and host bone without intervening connective tissue” GPT 1987 Fibro-osseous Retention can be defined as “tissue-to-implant contact with interposition of dense, healthy collagenous tissue between the implant and bone” (Misch) www.indiandentalacademy.com
Mechanism of osseointegration Similar to primary bone healing Initially, blood present between fixture and bone Blood clot formed Blood clot is transformed by phagocytic cells such as polymorphonuclear leukocytes, macrophages etc Most active during 1st and 3rd day of surgery Procallus formed containing fibroblasts, fibrous tissue and phagocytes This is differentiated into osteoblasts and fibroblasts
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Photomicroradiographs showing bone ingrowths after 12 weeks
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This connective tissue is callus Osteoblasts form osteogenic fibers which can calcify New bone matrix is formed and is known as bone callus Increase in density and hardness and remodeling takes place Occlusal stresses stimulate surrounding bone to remodel and osseointegration takes place Osseointegrated fixtures are surrounded by cortical and spongy bone
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Photomicroradiographs showing bone ingrowths in HA coated and non-coated implants
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Stage II surgery ď Ž
Uncovering of implants may be after 3 to 4 months of healing in mandible and 5 to 6 months in case of maxillae
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Cover screw is exposed after removal of overlying bone or soft tissue
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Hexagon cover screw driver used to remove cover screw from implant from abutment connection
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After 4 months of healing, cover screw removed
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Selection of proper sized abutment for transmucosal connection
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Abutment placed into fixture and secured with abutment screw
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Small or large healing caps used to prevent debris collection in threaded portion of abutment screw
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Surgical dressing during healing phase
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Tissue response after two weeks
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Hex abutment screwdriver to screw abutment screw into fixture
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Abutment placed with help from screwdriver
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Abutment clamp used to prevent transfer of torque to implant while connecting abutment screw
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Abutment clamp in use
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In case of multiple implants, same procedure is followed
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Preparation for laboratory procedure Components mainly used in fabricating prosthesis and making impression include the gold cylinder, the gold screw, the abutment replica, the impression coping, and the index pin www.indiandentalacademy.com
Impression coping is designed with a machined surface to to fit precisely to the abutment replica. The central portion is undercut to facilitate retention of the impression material
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Index pins are available in 10,15 and 20 mm lengths. These are used to secure the impression coping to the fixture in the mouth
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Impression coping is placed on top of fixture and is secured by the index pin
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Hole created in the tray for access to retrieve guide pin after impressioning
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Impression made with an elastomeric impression material
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Abutment replica is an brass analog of the abutment. Top surface is identical in shape and form to the abutment in the mouth
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Abutment replica in position in the impression, secured by the guide pin
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The gold cylinder is secured to the abutment replica with a slotted gold screw
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Coping has been cast and resecured to the cast with a gold screw
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A case of failing partially edentulous situation. Restored using 3 fixtures as anchorage
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Impression made with a suitable impression material
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Impression copings are in position
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Wax-up is sprued and cast
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Completed fixed prosthesis
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Implant Systems IMZ Dental Implant Systems Innova Endopore Implant System Nobel Biocare and 3i Systems Sulzer-Calcitek Implant System Friatec and Frialit Oratronics Spiral Implant Innovations incorporated
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IMZ Dental Implant Systems with Transmucosal Implant Extension and Intramobile Element
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It consists of a cylindrical, endosseous implant; a highly polished transmucosal implant extension (TIE), and a viscoelastic intramobile element (IME) This has been in use since 1978 It is made of commercially pure titanium The outer surface is titanium plasmasprayed with an electric arc, which gives rough texture and a large surface area Apical end of implant contains vent for bone ingrowth
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They are available in 3.3, 4.0 and 4.25 mm diameter and in lengths of 8,11,13,15,17, and 19 mm The Transmucosal Implant Extension (TIE) is an highly polished titanium sleeve that sits on top of the implant and extends up through the soft tissue Designed to be easily cleaned in situ by patient and can be removed by dentist for extraoral cleaning The Intramobile Element (IME) is made up of polyoxymethylene and provides a resilient connection between the implant and prosthesis
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4 mm IMZ implants in lengths 8,11,13 and 15 mm. Placement head assemble, titanium healing screw, second-phase sealing screw and TIE, IME and TIE
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They are developed by Interpore International, Irvine Indicated in totally edentulous, partial edentulous, class I and II and single tooth edentulous space IME is designed to minimize stress concentrations, by absorbing and distributing occlusal surfaces Abutments systems are two: the conventional TIE and IME ; the intramobile connector (IMC)
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Indications for IMZ implants: Completely edentulous patient rehabilitation
(1) custom tissue bar and clip-on overdenture
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(2) custom milled tissue bar and precision overdenture
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(3) implant supported, electively retrievable fixed prosthesis (boneanchorage bridge)
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For partially edentulous patients Implant is rigidly connected to the natural tooth using an extracoronal screwstabilized attachment Indicated for maxillary and mandibular posterior edentulous situations It distributes load between the implant and the natural abutment Possible if an semiprecision or telescopic attachment is used to connect teeth to implants
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Single-tooth abutment has been designed for use with IMZ implant In anterior regions of the mouth This titanium abutment is a two-piece insert Transmucosal section tightened against top of the implant body
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Transmucosal section tightened against top of the implant body Prefabricated ceramicor post and ring on the right designed so that when seated into abutment on left, post fits precisely over coronal aspect of abutment
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Completed crown ready for cementation
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Noble Biocare and 3i Systems Both systems are similar Packaged differently: glass tube and blister pack Various coating like hydroxylapatite (HA) and titanium plasma spray (TPS) are available Diameters– 3.75, 4, 4.5, 5, and 5.5 mm Branemark instrument names are used Procedure begins with guide drill to half its diameter at proposed implant site 2-mm twist drill to final implant depth
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Guide drill, 2-mm twist drill, counterbore drill, 3-mm twist drill, countersink drill, depth gauge
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Counterbore to enlarge the coronal portion of osteotomy in preparation for 3-mm twist drill 3-mm twist drill Counter-sink drill Depth gauge Screw tap Insert implant attached to fixture mount Wrench stabilizes fixture mount while fixation screw is removed Cover screw inserter Cover screw placement with small hexagon screwdriver
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Screw tap, implant with fixture mount, stabilization with wrench, cover screw inserter, small hexagonal screw driver
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Sulzer-Calcitek Implant System Available in 3.25, 4, and 5 mm diameters Principles applied can be used for other pressfit endosseous cylindrical implants Pilot drill for a depth of 8 mm Rosette bur to half its diameter over the pilot osteotomy Intermediate spade drill to enlarge pilot osteotomy for final depth preparation Counter bore drill to enlarge coronal portion Final spade drill Implant body try-in
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Pilot drill, rosette bur, intermediate spade drill, counterbore drill, final spade drill, implant body
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Seat implant with its plastic cap Tap implant into position Seat calcitek implants flush with crest of bone
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Innova Endopore Implant It has a surface macrostructure of sintered titanium beads This design greatly increases surface area and encourages high levels of intraosseous retention Technique for seating uses the classic bone enlargement drill, a steel try-in, and placement of implant in the press-fit mode
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Pilot drill, implant bur, trial fit gauge, implant placement
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Friatec and Frialit 2 These are stepped screw or press-fit TPScoated implants designed to increase primary stability in poor-quality bone Available in 3.8, 4.5, and 5.5 mm diameter Primary purchase point with a round drill Spade drill or twist drill used to full depth Enlarge receptor site to its final diameter using stepped drill Place implant into receptor site, first with finger pressure and then ratchet them into deeper threaded environment
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Round drill, twist drill, stepped drill
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Omni-R Guide drill at potential implant site Pilot drill to full predetermined depth Intermediate drill R2 Hand auger Seat implant in flush with crest of the bone
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Guide drill, pilot drill, intermediate drill, hand auger and implant seated
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Oratronics Spiral Guide drill used Pilot drill or spade drill to its final predetermined depth Spiral tap is attached to hand ratchet Enlarge the osteotomy to chosen length and width Implant attached to titanium insert, placed in the hand wrench and rotated to its final seating position
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Contd…..Part III Lab
procedures Prosthetic considerations Occlusion in implantology Implant failures Postoperative maintenance www.indiandentalacademy.com
Computer Assisted DesignComputer Assisted Manufacture (CAD-CAM) Technique Mainly stereolithographic laser model fabrication CT scan done with jaw stabilizing device Cast produced by stereolithography Articulation of cast by tube and stylus method Wax-up of cast done Casting completed Implant inserted by surgery
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CT scan intraoral stabilizing device
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Preimplant CT scanning
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Cast produced by stereolithography
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Cast hangs in space
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Surveying casts
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Design should extend into undercuts
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Wax-up with various attachments
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Tube and stylus method 5 orthodontic tubes inserted into flange area
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Tubes should accommodate 20 inch gauge hypodermic needles
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Infiltration given. Pierce mucosa till bone with needle through tube
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Patient keeps centric position maintained till all needles inserted
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Crimp each tube against needle to maintain needle position
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Five points now related to cast using the same base-plate with rim direct relationship between bone model and bite rim like in patient's mouth
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Centric and vertical relationship are transferred to the casts
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Casts related to each other on articulator
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Wax-up of articulated casts done
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