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«By Waad M. Kheder A thesis submitted in conformity with the requirements for the degree of MSc Prosthodontics Department of Prosthodontics University ...»

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Assessing The Position And Angulation Of Single Implants Restored In

The Predoctoral Dentistry Program

By

Waad M. Kheder

A thesis submitted in conformity with the requirements

for the degree of MSc Prosthodontics

Department of Prosthodontics

University of Toronto

© Copyright by Waad Kheder 2014

Assessing The Position And Angulation Of Single Implants Restored In The Predoctoral

Dentistry Program

Waad M. Kheder

Masters of Science

Graduate Prosthodontics

University of Toronto

Abstract Objective: to assess if single implants restored in the undergraduate clinic at the Faculty of Dentistry, University of Toronto, are placed in a compromised position and angulation relative to the adjacent natural teeth. Materials and Methods: The study sample consists of 108 patients treated with single implants placed in the Implants Placement Unit and restored by predoctoral students at the Faculty of Dentistry, University of Toronto. Assessing the angulation and 3D position of implant relative to adjacent teeth were conducted by using the measurement tool in the 3D scanner. Results: The highest percentage of the non-ideal implant position was for mesiodistal implant position and the lowest percentage was for the non-ideal buccolingual implant angulation. Conclusion: The placement of the implant in a non-ideal position/angulation may be due to: Gingival biotype, buccal cortical plate concavity, selected implant diameter and Implant site relation to vital anatomical structures and roots of adjacent teeth.

ii Table of Contents 1- Introduction …………………………….………………………………………………...… 1 2- Aim of Study……………………………………………………………………………..… 13 3- Materials and Methods……………….……………………...…………………………….. 14 3.1- Materials ………………………………………………………….……….…....…….. 14 3.1.1- Patients inclusion criteria based on undergraduate implantology protocol…….14 3.1.2- Stone Models …………………………………………………..……..…….….14 3.1.3- 3Shape D180 Scanner …………………………………………..…………..…16 3.1.4- 3Shape Dental Manager Software ……………….…………………………...17 3.2- Methods ………………………………………………………………………..…..….. 19 3.2.1- Stone model scanning ……………………………………….…………............19 3.2.2- Implant position assessment technique ………………………….………..........20 3.2.2.1- Mesiodistal implants position assessment ………….………………...20 3.2.2.2- Buccolingual implants position assessment ……………….….………25 3.2.2.3- Apicocoronal implants position assessment …………….……………28 3.2.3- Implant angulation assessment technique.…………………...……….…….…. 31 3.2.3.1- Mesiodistal implant angulation assessment ……..………………….....32 3.2.3.2- Buccolingual implant angulation assessment …..…………..........……35

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3.2.3.2.2- Anterior implant ………………………….....……………..38 3.3- Statistical Analysis …………………………………………………………………………40 4- Results ………………………………………………………………………..…….………...41

4.1. Mesiodistal Implant position (mesial side) ………………………………………….…41

4.2. Mesiodistal Implant position (distal side) ………………………………………….…..41

4.3. Mesiodistal Implant angulation (mesial side).…………………………………..……...43

4.4. Mesiodistal Implant angulation (distal side)……………………………………....……44

4.5. Buccolingual implant position (buccal side) ………….……………….………………45

4.6. Buccolingual implant position (lingual side)…….………………………………….…46

4.7. Buccolingual implant angulation (buccal side)……………………..……….…...….....47

4.8. Buccolingual implant angulation (lingual side) ……………………..………………....48

4.9. Apicocoronal implant position ………………………………………..……...…….…..49 5- Discussion ……………………………………………………………….………...………….52 5.1- Selected implant diameter……………………………….…

5.2- Gingival biotype ……………………………………

5. 3- Buccal cortical plate concavity ………………………………………………….….... 56

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……………………………………………………………………………………..….…57 6- Conclusion………………………………………………………………………………….…58 References……………………………………………….……………………….……………...59

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Fig. 1: Ideal implant position in the buccolingualdimension





Fig. 2: Ideal implant position in the mesiodistal dimension

Fig. 3: Ideal implant position in the apicocoronal dimension

Fig. 4: Defective tooth adjacent to the single implant

Fig. 5: Gingival recession of the teeth adjacent to the single implant

Fig. 6a & b: 3Shape D810 dental laboratory scanner (3Shape A/S, Copenhagen, Denmark)…. 16 Fig. 7: 3Shape D810 dental scanner: setting up the scan field

Fig. 8a&b: 3Shape dental manager software measurement tools

Fig. 9: A 2D cross section graph image

Fig.10a&b: Mesiodistal distance (distal), implant replacing tooth #11

Fig.11a&b: Mesiodistal distance (mesial), implant replacing tooth #11 …...……….................. 22 Fig.12a&b: Mesiodistal distance (distal), implant replacing tooth #36 ……

Fig.13a&b: Mesiodistal distance (mesial), implant replacing tooth #36

Fig. 14: Buccal sides of teeth adjacent to the implant as reference points, tooth#11

Fig. 15: Buccal sides of teeth adjacent to the implant as reference points, tooth #36

Fig. 16: Lingual sides of teeth adjacent to the implant as reference points, tooth #36..................27 Fig. 17: Lingual sides of teeth adjacent to the implant as reference points, tooth #11..................27 Fig. 18: Looking at a non-right angle to the occlusal surface of the implant #36

Fig. 19: Lingual sides of teeth adjacent to the implant as reference points, tooth #36….. …….. 28 Fig. 20a&b: Apicocoronal implant position in relation to adjacent teeth (teeth #11&36)…...29-30

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angulation

Fig. 22a, b & c: Mesiodistal angulation of implant replacing tooth #36…………………..…….34 Fig. 23a & b: Mesiodistal angulation of implant replacing tooth #11….……………….….……35 Fig. 24a & b: Buccolingual implant angulation-buccal height of contour as a reference point…36 Fig 25a & b: Buccolingual implant angulation-lingual height of contour as a reference point….37 Fig. 26a&b: Buccolingual implant angulation-buccal height of contour as a reference point.38-39 Fig. 27a&b: Buccolingual implant angulation-implant adjacent teeth cingula as a reference.39-40 Fig. 28: Mesiodistal implant position (mesial side) …………….….…………………….……...42 Fig. 29: Mesiodistal implant position (distal side)…………..…………………………………..43 Fig. 30: Mesiodistal implant position histogram…………………………………………….…..44 Fig. 31: Mesiodistal implant angulation (mesial side) …………..………………………………45 Fig. 32: Mesiodistal implant angulation (distal side)…………………………………...……..…46 Fig. 33: Buccolingual implant position (buccal side) …………………..……………………….46 Fig. 34: Buccolingual implant position (lingual side) ………..…………………………………46 Fig. 35: Buccolingual implant position histogram ……………….……………………………...47 Fig. 36: Buccolingual implant angulation (buccal side)……………...………………………….47 Fig. 37: Buccolingual implant angulation (lingual side)……...…………………………………48 Fig. 38: Buccolingual implant angulation histogram……………………………………………49 Fig. 39: Apicocoronal implant position………………………...………………………………..49 Fig. 40: Apicocoronal implant position histogram …...…………………….………………..….50

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Appendix A: Ethics Approval Form

Appendix B: Statistical Analysis Tables.……………….……………....…….………...........65

–  –  –

The placement of dental implants in a functionally and esthetically correct position and angulation is still considered a challenge in spite of major advances in surgical techniques and devices. Therefore, it is important to place the dental implants in a correct angulation and position in relation to each other, adjacent teeth, and to the underlying bone, since alveolar bone loss following tooth extraction often makes ideal implant placement difficult (Talwar et al., 2012). Furthermore, non-axial loading of implant-supported prostheses may occur due to incorrectly positioned and non-parallel dental implants which may cause improper occlusal load distribution, overloading of the implant and ultimately failure of osseointegration (Saab et al., 2007; Talwar et al., 2012). In addition, parallelism between dental implants supporting overdentures is important to achieve complete seating of retentive elements, predictable attachment retention, prevention of premature wear of the involved components, and provision of axial loading (Gulizio et al., 2005).

One of the important factors leading to dental implant failure after fabrication of prostheses is overloading; therefore, successful implant placement requires accurate positioning and angulation to achieve a predictable esthetic result and resistance to heavy occlusal forces (Payer et al., 2008; Al-Harbi & Sun, 2009; Talwar et al., 2012). According to an early report, 20 percent of implants which were located too far palataly had bone loss greater than 2 mm (Cummings & Arbree, 1995).

The use of dental implant therapy in the treatment of dentate patients has become a wellestablished clinical procedure due to its predictability and success in practice (Afsharzand et al., 2005; Petropoulos et al., 2008). The successful application of implants to restore edentulous sites has captured the interest of the public (Wilcox et al., 2010). In our information technology era, patients have become more educated and value how dental implants may improve the esthetics, function, and oral health, and prevent the adverse psychosocial impact of the loss of all or some of their natural teeth (Gulizio et al., 2005).

In order to meet the increase in patient expectation about dental implant treatments, predoctoral dental students must be familiar with the indication of implants and able to offer treatment at the proper level (Lee et al., 2011). Thus, it seems universally accepted to include straight forward cases for implant therapy in the dental predoctoral curriculum in most dental schools worldwide since implant-supported single-tooth replacements showed few biological and technical complications as well as high survival rates (Bonde et al., 2010). The introduction of implant dentistry education greatly varies from one school to another. For example, at the University of Illinois-Chicago College of Dentistry, responsibilities of predoctoral dental students as part of a predoctoral implant program include: a complete dental examination, consideration of the patient’s medical history, identification of diagnostic criteria for implant placement, diagnostic wax-ups, fabrication of radiographic and surgical templates, and assisting in surgery (Lee et al., 2011).

However, the majority of schools allow predoctoral students to practice only the restorative part of implant treatment; some schools include an additional didactic part and laboratory instruction course in the curriculum (Kronstrom et al., 2008). In the United States, 36% of dental schools allow students to restore implants, 42% offer laboratory instruction in implant dentistry, and a small number of dental schools allow students to place the dental implant (Huebner, 2002). In contrast, Bavitz reported in 1989 that two percent of the undergraduate dental students participated in the surgical stage of implants therapy and 11% provided restorative care for implant patients (Maalhagh-Fard et al., 2002).

Some studies found that exposing students to dental implant therapy at the predoctoral level is directly related to an increased use of implants later in general practice (Maalhagh-Fard et al., 2002). A survey conducted at the School of Dentistry/ University of Detroit Mercy found a strong correlation between student participation in a predoctoral implantology elective program and the use of implant restorations in their practices after graduation (Kido et al., 2009). Lee et al. (2011) found that a predoctoral implant program can provide predictable patient-centered therapy with few complications. The difficulty of incorporating dental implants in the predoctoral curriculum may be due to several logistical barriers including lack of curriculum time (53%), limited financial resources (28%), limited assisting staff (51%) and limited number of patients who fulfill the educational criteria in relation to a large number of students (Weintraub et al., 1995; Ghani & Moeen, 2011).



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