Despite the fact that dentistry has changed progressively over the past 50 years and today its capabilities greatly enhanced, but the problem is the prevention of edentulous it continues to be one of the most acute.
Even assuming that current trends in the treatment of periodontal disease as the main cause of tooth loss achieved considerable success, not fully resolve the outstanding issues and parafunktsy treating traumatic injuries. Therefore, treatment with the use of dental implants is a promising and urgent approach to the treatment of edentulous.
Patients should understand the importance of keeping their own teeth throughout their lives. It has been found that ensuring the adequate supply of health is a determining factor that plays an increasingly important role in the aging process of the body.

Edentulous is a major factor in violation of the procedure of physiological meals. In nursing homes, about 80% of people are toothless, and a high rate accurately is not accidental. In most of these institutions adentia level determines the level of necessary care for each individual patient, because the presence of edentulous not only affects the quality of life, but may be affected and its duration. Dental implantation is an increasingly popular approach to the treatment of edentulous patients with symptoms, and doctors regard it as an opportunity to rehabilitate the patients, even in the most challenging clinical situations.

implantation protocol SAFE

SAFE implantation protocol provides for simple (simple), accessibility (affordable), speed (fast) and aesthetic (esthetic) the results of an manipulations. The author of the article suggested the use of the integration methods of cone beam computed tomography (CBCT) and CAD / CAM technologies for optimal workflow and achieve the most effective results. Using this approach allows for patient rehabilitation in just 3 visits, making a total of not more than 2 hours of clinical time. Since the goal of treatment is to achieve the most functional and aesthetic changes, the recovery procedure begins with the manufacture of ceramic crowns with screw fixation. SAFE implantation protocol is not only the most appropriate in terms of time saving, it also helps to achieve the aesthetic appearance of prosthetic restorations.

patient selection

With the implementation of the protocol SAFE is an important aspect of it is the selection of patients for future manipulation. The selection as simple as possible clinical cases is extremely important for the practice of novice doctors implantologists. The ideal patient somatic can be described as completely healthy, non-smoker, with no evidence of systemic diseases and symptoms of periodontal lesions. Area adentia should look completely healthy, with no signs of inflammation, with an adequate amount of keratinized gingiva and the optimal parameters of the alveolar ridge. If the patient does not meet the criteria mentioned above – it does not mean that the implantation SAFE-protocol he is impossible: in case of insufficient amount of keratinized soft tissue, or with a deficit amount of bone tissue can be carried out procedures appropriate augmentation and thus, their own form suitable conditions for the future implantation.

Evaluation of bone volume

CBCT is the most accurate diagnostic tool for the assessment of bone volume. Many CBCT scanners already available with proprietary digital software for planning the implantation procedure. There are also open for the use of programs that can work with any file CBCT data. implant planning using CBCT and software is the basis for the implantation protocol SAFE. It is impossible, however, to say that doctors without direct access to the CBCT scanner or CAD / CAM system for milling can adapt this protocol to the opportunities available to them, but the use of these technologies greatly simplifies the workflow, allowing complete patient rehabilitation for the three visits.

workup

The first clinical examination of the patient is diagnostic. During the first visit to the estimated general medical and dental history of the patient and the results of diagnostic CBCT. In parallel, the analysis of plaster models for the purpose of verification of occlusal abnormalities. It is equally important to conduct a thorough examination parodontological. In the presence of periodontal lesions or occlusion disorders the patient first is the treatment of pathologies existing and already then considered plan for future implantation.

During the clinical examination parameters estimated residual ridge in edentulous: the amount of bone tissue in the vestibular-lingual and mesial-distal directions. The smallest diameter standard implants is 3.0 mm and their replacement platform – 3.5 mm. In this case the minimum distance to adjacent teeth should be at least 1.5 mm, and the mesial-distal space should be at least 6.5 mm (3.5 mm + 1.5 mm + 1.5 mm). Given the need for a 1 mm of the vestibular and lingual bone infrakonstruktsii, plus at least 1.5 mm thickness on each side of the gum, to set the minimum width required implant ridge about 8 mm (1 mm + 3 mm + 1 mm + 1.5 mm + 1.5 mm). Be sure to carry out palpation of the area of ​​bone tissue in order to verify possible undercuts that occur frequently apical muco-gingival line. These areas need to study in detail on the CBCT-Reformed, as they significantly affect the position of the implant and the level of its angulation relative to adjacent anatomical structures.

There is some disagreement about the proper amount of keratinized gums, providing aesthetic designs implant, but it is obligatory to have at least 2 mm of soft tissue attachment. For SAFE protocol is desirable to have at least 3 mm of keratinized gum, based on the fact that it is the amount of soft tissue can provide a predictable aesthetic results. A simple method for estimating the width of the gums is periodontal probe positioning in front of the cement-enamel junction of the adjacent teeth. At the mid-point between adjacent teeth lingual boundary of the implant must end ligvalnee 2 mm from the tip of the border. Therefore, if the cover keratinized tissue ligvalnee 1mm border probe, it will be sufficient to provide relatively implantation aesthetic results. If the bone or soft tissue did not meet the minimum requirements for implantation, it is a mandatory procedure for soft tissue augmentation or tverdotkannoy, with which you can achieve adequate parameters gingival and alveolar ridge. Upon reaching the necessary conditions for the implantation of the next stage is to obtain digital prints both jaws.

treatment planning

After the clinical examination begins planning stage of the operation, the timing and final prosthetic designs. The attention to detail at this stage of treatment provides time savings in subsequent clinical techniques. The first step is the design of the future prosthesis. If this stage is carried out with the help of CAD software / CAM (photo 1), the project file should be sure to save in a format compatible with the software used for planning the implantation procedure itself.

By using the wax reproductions, it must be scanned by a laboratory or doctor’s CAD / CAM scanner and then save the file in a compatible format. Once you have decided on the design of orthopedic designs, you should move on to the evaluation reformate CBCT scanning software, adapted to the planning of the implantation procedure. One of the most important points of this stage – to conduct trace the inferior alveolar nerve, to prevent the possibility of iatrogenic injury (photo 2).

Photo 2. CBCT-image with tracing the inferior alveolar nerve.

After that produce import prosthetic component file in the software for the planning stage of implant treatment. Comparison of images is carried out using fiducial reference points so that the data sets of graphics data coincided maximum. As these guidelines is not desirable to use a large piece of the crown or restoration, as the latter provoke artefacts on reformate CBCT that in the future will lead to inaccuracies when comparing the images. After you import the image matching accuracy is determined by the user, who can accept the proposed version of the integration of data, or reset it and start over. Using this approach, the optimal implant position is determined not only by the anatomical conditions of the edentulous area, but also features prosthetic component. At the same time determined by the size of the restoration and the implant (length, diameter, angulation, installation level). After the program alone will position the implant, the user can manually adjust the position, change the length, width and level setting infraossalnoy design.

The diameter and length of the implant

An important part of the planning process is the choice of optimal treatment parameters and the diameter of the implant length for each specific area of ​​edentulous. In the area of ​​the lower incisors and lateral incisors of the upper jaw implants can be used with a diameter of 3.0 – 3.5 mm for the central upper incisors, canines and premolars of both jaws – with diameters of 4.3-4.5 mm. To replace molars, tend to use implants with a larger diameter – 5.0-6.0 mm.

Furthermore, the choice of optimal diameter also affects the type of bone is present, which depends on its density and the relationship of cortical and trabecular components. Classification according to these parameters provides four possible types of quality of residual bone crest. Cortical bone is responsible for part of the primary mechanical stability of the implant, while cancellous provides the blood supply necessary for successful osseointegration. The diameter of the implant must provide its bikortikalnuyu stability by contact with both the buccal and lingual cortical plates must be kept at the same distance from the adjacent teeth, at least 1.5 mm. The software alone generates 1.5 milimmetrovuyu “security zone” around the implant, thus helping the dentist to determine the necessary diameter and optimal spatial infrastructure position. EVIDENCE sufficient graft length is about 13 mm. On the lower jaw, it should be mindful of rule 2 mm – the required minimum distance from the top of the screw to the area of ​​the inferior alveolar nerve, which minimizes the risk of paresthesia. The upper jaw to ensure adequate stability of the primary parameters as reference areas may be used the bottom of the maxillary sinus and nasal cavity bottom. The implant does not penetrate into these anatomical structures deeper than 2 mm, unless, of course, we are not talking about the installation of the implant in the posterior region of the mandible to the planned conduct of sinus lift procedures. An equally important factor is the infrakonstruktsii angulation, which is largely determined by its spatial position in the bone and the future relationship with the prosthetic component.

Angulation and implant installation depth

Angulation of the implant should take into account the direction of occlusal forces, which in an ideal position infrastructure should be directed along the long axis. Thus, the implant center and a hole for screw fixing prosthetic design must coincide with the position of the central fissure in posterior teeth and be focused strictly on the axis to the Mount of tooth antagonist opposing jaw.

SAFE protocol involves the use of prosthetic screw fixation. It is important to assess the implant position relative to the front of the concavity of the upper jaw if to avoid penetration of the vestibular cortical plate is impossible, it is necessary to hold the ridge augmentation to increase the amount of bone tissue. One level of depth in implant placement more influenced by two factors: the distance to the proximal pins, and having at least 1 mm of bone around infrakonstruktsii titanium. implant platform should be at least 5 mm from the proximal contact area, then we can talk about the formation of a predictable esthetic gingival papilla. Given the parameters of the future prosthesis, distance to the occlusal surface should be approximately 7 mm (5 mm + 2 mm abutment ceramics).

If even when the platform directly to the surface of the bone crest can not achieve these parameters need to carry out the reduction of bone and place the implant at the desired depth. However, in cases where the distance from the platform to the occlusal surface of the future prosthetic restoration is 7 mm, and there is no bezel around the implant bone tissue with a minimum of 1 mm thickness, it is necessary to take a decision on further treatment algorithm. Bone deficit is usually observed from the front. In such cases, the practitioner must either place the implant deeper in order to achieve an adequate thickness of the bone around the screw, or even spend augmentation before step direct implantation.

Existing methods for guided bone regeneration provide bone growth up to 5.5 mm in the horizontal direction and 10 – 12 mm in the vertical. After completion of the design position platform physician can finally determine the working length of the implant, and thus complete digital manipulation the planning stage (picture 3).

Photo 3. The implant planning intervention: installation of the implant, the abutment and the contouring of the inferior alveolar nerve.

The file held planning electronically sent to a laboratory for the production of a surgical template. Depending on the performance of the laboratory, the templates can be produced in the period from 2 to 10 days. After receiving the template to the patient can be given a date for the second visit of the surgery.

Temporary construction

In cases where, after implantation provides direct structural load, it is advisable to use a provisional prosthesis. This is achieved by modifying the implant analogue in a plaster model using a surgical template. An analog set in the implant and placed in the surgical template. The template is positioned on the pattern after removing the gypsum volume required to adapt the analogue. After that, the area is filled with plaster analogue to the latter to take a hard line (photo 4). To be sure that the implant takes the same position in the oral cavity, the guide is made of polyvinylsiloxane implant template (impression material) (Picture 5). Then set a temporary abutment design and CAD / CAM crown with screw fixation. Crown attached to the abutment, and thus end the process provizionalizatsii (temporization provisionally constructs). Alternatively, as bits can be used acrylic blank with a hole for fixing in temporary abutment.

Photo 4. Installing the implant analog according to the direction of the surgical template.

Photo 5. The implant guide key on the layout template from polyvinylsiloxane for adequate insertion of the implant in the mouth.

Surgical treatment of stage

The surgical phase of treatment is the fastest thanks to the use of surgical template. During the procedure, use standard surgical protocol: after anesthesia is performed the bone bed preparation and subsequent implant placement.

SAFE Protocol provides for the implementation of flapless surgery as a possible deficit of soft tissue and its correction are taken into account at the stage of preparation for surgical implantation. The implant procedure usually takes up to 15 minutes. Once the implant has been installed, its position is checked by means of X-rays, and the installation area is scanned by the medical CAD / CAM scanner for producing final prosthetic design.

To scan the implant in it, an appropriate scanning pin, which is fixed on the body scan. The pins and the housing are specific scanning elements for different medical CAD / CAM systems are used in clinical practice. Some implant manufacturers as well as major commercial laboratories offer a universal version of the data elements to unify the production process. The form of the upper part of the body scanning provides information about the depth, angle and inclination of the implant platform installation time. After scanning the area of ​​implantation to scan both jaws, as well as their status in the bite.

After the data set manipulation patient conditioners gum or a provisional design, provides a number of post-operative advice and go home.

Designing the final design

So far made the final prosthesis, the implant passes through the stage of osseointegration. For rehabilitation SAFE protocol provides the use of ceramic crowns, screw-retained, since they can achieve adequate soft tissue contour and are themselves the best aesthetic option for restoring the lost teeth. In addition, the use of these structures of cement eliminates the possibility of falling into the subgingival area, which in the future may trigger symptoms of peri-implantitis.

Ivoclar Vivadent IPS e.max abutments makes already pre-formed holes for the screws, which corresponds exactly to the parameters Sirona TiBase. Sirona also makes inCoris Meso abutments of zirconia with the same access opening. There are other companies that made TiBase abutments, but they usually do not correspond to those manufactured by Ivoclar or Sirona. According to the author, the use of these proven abutment crowns significantly optimizes the manufacturing process of screw-retained and implant. After milling design is processed in furnaces for porcelain and is connected to TiBase by an appropriate cement (photo 6). If the doctor is not available CAD / CAM technology, it can remove the impression of using PVA material and send it to the lab, where technicians will make the final prosthetic superstructure.

Photo 6. A crown with screw fixation.

Installation of the final designs

During the latter, the third visit of the patient is carried out setting the final prosthetic. After confirmation, the implant osseointegration doctor removes gum formers or provisionally design and trying a final prosthesis. After checking the proximal contacts and X-ray analysis of fit accuracy are checking occlusal relationships. The locking screw is tightened accordingly the recommendations of the manufacturer, then the access hole is filled with Teflon tape to prevent ingress of flowable composite in the region of the screw. With adequate restoration of the hole becomes virtually invisible (photo 7). This step is the final process in the edentulous patient rehabilitation through implantation for SAFE protocol.

Photo 7. View the crown fixed on the implant with the access hole in disguise.

Conclusions

SAFE implantation protocol provides an optimal treatment process of patients with partial or complete loss of teeth, allowing to achieve a functional and aesthetic results by substituting edentulous using implants and crowns with screw fixation. In addition, short period clinical robots advantageous not only to a physician, but also is more comfortable for the patient. Using CBCT and CAD / CAM technologies progressively affects the quality of care while reducing costs through economies of clinical treatment time practicing dentist.

Author: Gregory Scott Sauer, DDS, http://stomatologclub.ru/stati/implantologiya-14/implantologicheskij-protokol-safe-1260/60/

About the author

Доктор стоматолог. Лечение зубов в Виннице. Ул. Н, Оводова, 51 (SkyPark, корпус 1) www.dentaltravel.in.ua, +380673468508/ +380674324689/