October 13, 2025 • 23 mins
An extensive overview of implant dentistry, focusing on the prosthodontic principles for restoring both fully and partially edentulous patients. Content is structured around various clinical scenarios, including the restoration of the edentulous maxilla and mandible using overdentures and fixed prostheses, as well as specialized topics like implants in irradiated tissues and orthodontic applications. Significant attention is given to implant biomechanics, encompassing factors such as screw retention versus cementation, implant angulation and positioning, and the impact of different prosthetic materials like metal-ceramic and zirconia. Furthermore, the text examines the biologic sequence of osseointegration, discussing variables such as surface topography and the challenge of managing peri-implantitis and bone resorption.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Welcome to the deep dive today. We are really digging
into something foundational. We've got Volume one of Fundamentals of
Implant Dentistry Proseidontic Principles right here, and our mission, well,
it's pretty intense. Actually, we're going to drill down into
those core biological mechanisms, the clinical strategies, basically everything that
defines modern implant success. So if you're a dental student,
(00:23):
maybe a young professional starting out, or just you know,
really keen on understanding this, feel deeply. We're aiming to
distill every critical concept. We want to show how pretty
much every major clinical decision, whether it's picking an attachment
or even planning something complex like a zygomatic implant, it
all comes back to the biology, the microscopic stuff we're
about to get into.
Speaker 2 (00:43):
Absolutely, and you really can't talk about modern implantology without
going back to that pivotal moment, the nineteen eighty two
Toronto conference that's where per Ingvar Brona Mark introduced osteo
integration change. Everything didn't it completely Yeah, it wasn't just
oh here's a new technique. It was a fund the
mental shift. It basically forced the entire field, especially prostendontics
(01:05):
to put the long term biological health of those tissues
around the implant first and foremost. That set the stage
for everything in this book.
Speaker 1 (01:13):
Okay, so let's unpack that biological basis because long term success,
it's not really about the titanium itself, is it. It's
about how the body responds.
Speaker 2 (01:22):
Precisely, it's the host response. We know ossio integration means
bone growing directly onto the implant surface. But maybe we
should start with the soft tissues first.
Speaker 1 (01:32):
That critical barrier, right, the biological width. I remember learning
about that for natural teeth. How does it apply here?
Speaker 2 (01:37):
Well, it applies directly. It's that combined height of connective
tissue and junctional epithelium just above the bone crest. For implants,
it averages around three millimeters.
Speaker 1 (01:46):
Okay, three milimeter. That's a bit more than the roughly
two milimeter for natural teeth, isn't.
Speaker 2 (01:50):
It slightly more? Yes? And that extra millimeter or the
whole three milimeter, really it matters hugely, especially upfront in
the esthetic zone. Why because the level of the bone
underneath that dictates where your gums are going to sit
the contour.
Speaker 1 (02:05):
So mess with that three millimeter space and you're looking
at potential recession or bone loss down the line.
Speaker 2 (02:10):
Exactly, you have to respect it. It's fundamental. The bone
crest position controls the gum line, simple as that.
Speaker 1 (02:16):
Okay, bone controls the soft tissue contour. Now let's shift
to the hard tissue. That implant surface. It's not just passive, right,
it's doing something.
Speaker 2 (02:25):
Oh, definitely, the texture is key. Nowadays we mostly use
moderately rough titanium surfaces, and the research is clear these
surfaces are excellent at getting platelets activated and forming a
really strong fibrine clot.
Speaker 1 (02:37):
And that clot is the scaffolding for healing.
Speaker 2 (02:39):
Right, It's the essential first step. It kick starts the
whole healing cascade. What's kind of fascinating, though, is that
in other areas like vascular stents, which also use similar surfaces,
they actually want to reduce platelet sticking.
Speaker 1 (02:51):
Huh. So the same surface does opposite things depending on
where it is in the body.
Speaker 2 (02:56):
Exactly. It tells you the bone environment has a very specific,
complex reaction. But for us in implant dentistry, that moderate
roughness is absolutely critical for good initial healing.
Speaker 1 (03:06):
All right, Now, here's where I think it gets really
really interesting. The actual bone that forms around the implant.
It's not just any old bone, is it.
Speaker 2 (03:13):
No, it's quite unique. The bone that forms right up
against the implant surface. This happens through a process called
contact osteogenesis. It actually shows higher levels of specific enzymes
involved in collagen cross linking. We're talking in things like
P four H and CR tap okay, hold.
Speaker 1 (03:29):
On P four h crt app. So translating that, does
it mean the bone being formed is like tougher, stiffer,
more like cortical bone.
Speaker 2 (03:39):
That's a great way to put it. It's creating this
really robust, stiff shell right around the implant, and that's
why it holds up so well long term under chewing forces.
This specialized bone resists the normal breakdown process, the catabolic
remodeling that usually gets rid of weaker woven bone form
during initial healing.
Speaker 1 (03:54):
So it's built to last from the start pretty much.
Speaker 2 (03:57):
And this understanding actually led us to question and older measurement.
We relied on heavily bic or bone to implant contact.
Speaker 1 (04:05):
Right just measuring how much surface area was touching bone exactly.
Speaker 2 (04:08):
We used to think higher bic automatically meant stronger but
then studies came out showing that moderately rough implants compared
to smooth ones might have similar BIC percentages. Okay, but
the rough implants had three times the sheer strength, three
times the resistance to being pulled out sideways.
Speaker 1 (04:25):
Wow. So it's not just about touching, it's about the
quality of.
Speaker 2 (04:28):
The grip precisely. It suggests there's actual biological bonding happening
at that interface, maybe involving specific molecules. Some people think
TYPEX collagen like you see in cartilage development. It's a
bond much stronger than just simple physical contact.
Speaker 1 (04:42):
Okay, let's shift gears from the micro level to the
bigger clinical picture, the fully identialist mandible. That's often cited
as one of the biggest challenges, right, mostly because of
bone loss.
Speaker 2 (04:52):
Oh, it's a major headache. The bone resorption is aggressive.
Most of it happens really fast in the first say,
six to eight months after teeth are lost, but then
it just keeps going slower maybe but continuously throughout life.
Speaker 1 (05:06):
And it's not just random, is it? There might be
a genetic component.
Speaker 2 (05:09):
There seems to be. Some pile studies are starting to
link specific genetic markers smps single nucleotide polymorphisms in a
gene called fgf R one op two. What are three
point zero to really severe mandibular atrophy SMP?
Speaker 1 (05:22):
So tiny variations in DNA. You're saying some people might
just be genetically programmed for more severe bone loss.
Speaker 2 (05:28):
That's the implication. Yeah, imagine a future where we could
do a quick genetic screen and identify patients at super
high risk before they even lose their teeth. That could
totally change how we approach their treatment right from the start.
Speaker 1 (05:39):
Fascinating Now, clinically, how do implants help these patients? Comparing say,
traditional dentures to implant overdentures.
Speaker 2 (05:47):
Well, the studies are interesting. Implant retained over dentures or
iods didn't necessarily lead to massive improvements in overall nutrition
compared to good conventional dentures CDs.
Speaker 1 (05:57):
Oh I would have expected a bigger difference me too.
Speaker 2 (06:00):
Initially, but what they did show was significantly better showing performance,
especially for patients who already had severely resorbed mandibles. They
could just process food much more effectively. Even if their
diet choices didn't drastically change, they felt like they could
eat better.
Speaker 1 (06:16):
Makes sense, so when we opt for an iod maybe one,
using just two implants up front with something like a
hater bar, how does that design work biomechanically? How does
it protect those implants?
Speaker 2 (06:28):
Ah? The hater bar clip system is a classic implant
assisted over denser. The keyword is assisted. It's clever because
it shares the load. The denture can actually rotate slightly
around the bar when the patient bites down on the
back teeth.
Speaker 1 (06:41):
Okay, so it pivots exactly.
Speaker 2 (06:43):
So the implants handle the forces in the front, but
the main chewing load in the back still gets distributed
onto the patient's own tissues, the buckle shelf area, the
retromolar pads. This sharing minimizes twifting or torquing forces on
those front implants, which is really crucial for their long
term survival, especially with just two.
Speaker 1 (07:00):
Right now, what if we go for a fully fixed solution,
the classic Brona Mark style fixed hybrid prosthesis. What are
the absolute must follow rules there? Biomechanically?
Speaker 2 (07:13):
Load management becomes even more critical. Two numbers are key. First,
your ap spread. That's the distance from the center of
the most forward implant to the center of the most
backward implant on one side.
Speaker 1 (07:24):
Anteroposterior spread.
Speaker 2 (07:25):
Got it. That AP spread needs to be at least
one centimeter minimum second. Any candilever, the part of the
bridge extending backward past the last mplant generally shouldn't be
more than two times that AP spread, and usually there's
an absolute max limit, maybe around twenty milimeters, regardless of
the spread.
Speaker 1 (07:42):
It's like wheelbase on a car, isn't it. You need
a decent wheelbase AP spread before you can safely hang
much weight off the back cantilever. A short wheelbase with
a long overhang is just asking for trouble.
Speaker 2 (07:53):
That's a perfect analogy spot on And another critical point
anatomically trying to place implants way back post steerity to
the mental forum and in a fully identialist mandible, it's
usually not needed, and it's actually risky. Why risky Because
a mandible flexes. It actually bends inwards when you clench hard,
sometimes up to a full millimeter in the moldar.
Speaker 1 (08:13):
Region a millimeter wow.
Speaker 2 (08:14):
Yeah, And that much movement means you absolutely cannot rigidly
splint implants across that bending zone. It creates huge stresses,
so you generally stop implants just in front of the
mental forum.
Speaker 1 (08:26):
And the materials for these fixed bridges have evolved too, right, Oh, definitely.
Speaker 2 (08:30):
The original hybrids were acrylic teeth processed onto a metal bar.
They worked, but the acrylic wears it can stain, its
porous hygiene can be tough. Now we're seeing a big
shift towards metal ceramic options or even full monolithic zirconia.
They look great, they're superware resistant and much easier to
keep clean because they're non porous. Okay, shifting upstairs to
(08:51):
the maxilla, totally different ballgame here. The bone tends to
resorb inwards from the cheek side towards the palate lebiobucle
to lingle and.
Speaker 1 (09:00):
Creates problems, doesn't it.
Speaker 2 (09:01):
It often leads to what looks like a Class three
jaw relationship, even if the patient wasn't originally Class three.
The upper jaw just collapses inwards. This means you often
need a flange that pink part of the denture to
provide lip support and restore the facial profile.
Speaker 1 (09:16):
Which often makes an overdensure a better choice than fixed,
especially for older folks.
Speaker 2 (09:21):
Exactly, over dentures are often highly favored in the maxilla
for that reason. Restoring lost tishoe volume and lip support.
Speaker 1 (09:27):
And honestly, quite often a conventional maxillary denture works really well.
Doesn't it much better than a lower one? Usually?
Speaker 2 (09:34):
Absolutely, you've got the whole palette for suction that peripheral
col You generally have a broader base of support, and
the bone resorption is typically slower and less severe than
in the mandible. So often a well made conventional upper
dentsure is perfectly adequate.
Speaker 1 (09:50):
So when do we really need implants in the maxilla?
What pushes us towards that?
Speaker 2 (09:56):
Well, sometimes it's patient demand. They just hate having their
palate covered. Psychologically they want it open. That's big driver.
Or sometimes the retention fails even with a good venture base,
usually because of severely dry mouse maybe from stogrin syndrome
or head of neck radiation. If you can't get that
peripheral seal because there's no saliva, implants might be the
(10:17):
only way to get.
Speaker 1 (10:17):
Stability and biomechanically. You mentioned the bone up there is
usually weaker, poorer quality.
Speaker 2 (10:23):
Generally, yes, often type three or even type four bone.
It's just not as dense as the typical lower jawbone,
and often there's less quantity too, especially vertically.
Speaker 1 (10:33):
So what does that mean for planning?
Speaker 2 (10:35):
It means you have to over engineer things. You can't
cut corners. For a fixed prosthesis in the maxilla, the
recommendation is usually a minimum of six implants well spread
out actually aligned if possible, and you need a good
apiece spread at least two centimeters this time.
Speaker 1 (10:49):
Six implants two centimeters eight piece bread minimum for fixed
Got it?
Speaker 2 (10:53):
What if there just isn't enough bone for standard placement.
Speaker 1 (10:56):
That's where we get into more advanced techniques for the
really resorbed maxilla. One option is using angled implants like
in the all on four concept, or even trans sinus implants.
Speaker 2 (11:05):
How do angled implants help? By tilting the postcuar implants,
you can use longer implants, maybe fifty percent longer, because
you're engaging denser bone often found near the floor of
the sinus or the pure form rim further forward. This
also helps achieve that crucial apiece spread without extensive grafting.
Speaker 1 (11:22):
And if even that's not enough, if the atrophy is extreme.
Speaker 2 (11:25):
Then you might consider zygomatic implants. These are very long
implants that bypass the maxilla entirely and anchor directly into
the zygoma the cheekbone.
Speaker 1 (11:34):
Wow, that sounds complex.
Speaker 2 (11:36):
It is. It's very demanding surgery requires specialized training, but
the success rates are actually quite high and it can
be a fantastic alternative to massive bone grafting procedures in
severely a trophic cases.
Speaker 1 (11:48):
Okay, let's zoom in again, this time to partially addentialist cases. Specifically,
the posterior area is replacing molars or premolars. Here, the
implants often end up in a straight line, right exactly.
Speaker 2 (11:59):
You usually just fill a gap between existing teeth. That
linear arrangement is the big biomechanical challenge back there.
Speaker 1 (12:05):
Why is it such a challenge Because you.
Speaker 2 (12:07):
Lose that Crosshart stabilization you get in a full arch
case imagine trying to balance on a tightrope versus standing
with your feet apart. The linear setup is much less
stable against forces that aren't straight down the long axis
of the implant's lateral forces. Twisting forces, so.
Speaker 1 (12:23):
More vulnerable to sideloads.
Speaker 2 (12:25):
Extremely vulnerable. And that's why the number one rule for
fixed partial dentures fpds supported by implants in the posterior
is no cantilevers. Period. Don't hang a tooth off the
end of the last implant, it puts tremendous stress on
that implant and the components.
Speaker 1 (12:40):
Okay, no cantilevers non negotiable. How do we decide how
many implants to use them and how big should they be?
Speaker 2 (12:47):
Well, for a typical gap, say replacing two premolars in
a first molear a three unit FPD in the mandible
where bone is usually good, two implants are often enough,
one at each hand.
Speaker 1 (12:57):
But what about trickier situations.
Speaker 2 (12:59):
Right if you're replacing say four units, or if you
have to use shorter implants maybe less than ten millimeters long,
or if you know the patient grinds heavily bruxism or
has a really strong bite like a brachycephalic facial.
Speaker 1 (13:11):
Type, square jaw, heavy muscles.
Speaker 2 (13:13):
Exactly in those cases, adding a third implant in the
middle is a very wise move. It just distributes the
load much better. And in terms of size, you want
robust implants back there. Never go too narrow. The recommendation
is generally at least four point zero millimeters in diameter
to minimize the risk of the implant itself fracturing under
heavy chewing forces.
Speaker 1 (13:33):
Okay, robust implants, maybe add an extra one for heavy loads.
Since those lateral forces are the enemy. How do we
design the chewing surfaces the occlusion on the crowns.
Speaker 2 (13:44):
The absolute goal is to minimize any sideways forces hitting
the implants. So if the patient already shows signs of
wear on their natural teeth suggesting they might grind or clench,
then a mutually protected occlusion is generally preferred.
Speaker 1 (13:58):
Meaning the front teeth guide the jaw during sideways movements,
discluding the.
Speaker 2 (14:01):
Back teeth precisely. The anterior guidance protects the postery implants. Now,
if there are no obvious signs of problematic occlusion, then
group function where multiple teeth share the load during side
movements might be acceptable.
Speaker 1 (14:14):
And the shape of the faked teeth themselves, you have.
Speaker 2 (14:16):
To be smart about the design. Narrow the chewing table,
don't make the implant crown as wide as a natural molar,
keep the cusp angles shallow, not steep and pointy, and
critically make sure the main contact points during chewing are
centered right over the long axis of the implant body.
Speaker 1 (14:33):
How do you achieve that centering.
Speaker 2 (14:35):
Clinically for lower fpds that often means a lingualized contact
scheme for upper fpds, it might be more buccalized. You're
basically shifting the main force vector inwards or outwards slightly
to line up with the implant underneath.
Speaker 1 (14:49):
Makes sense. Now, what if the site isn't ideal, not
enough bone height, especially in the upper posterior over the sinus,
or maybe not enough width anywhere.
Speaker 2 (14:58):
Site deficiencies are common for vertical height problems in the
maxilla sinus augmentation, lifting the sinus membrane and placing bone
graph material is a very predictable procedure, lots of long
term data on that.
Speaker 1 (15:10):
But what about vertically in the mandible, especially back near the.
Speaker 2 (15:12):
Nerve AH, that's much trickier. Trying to gain vertical bone
height on top of the ridge over the inferior alveolar
nerve using traditional bone graphs is generally quite unpredictable and
carries risks to the nerve. It's not something done routinely.
Speaker 1 (15:27):
So if you need more height there, if.
Speaker 2 (15:29):
You have at least say four to five millimeters of
existing bone above the nerve canal, then distraction osciogenesis becomes
a viable option.
Speaker 1 (15:37):
Distraction that's where you cut the bone and slowly pull
the segments apart exactly.
Speaker 2 (15:41):
You make a surgical cut, attach a device, and then slowly,
fraction of a millimeter per day, you separate the two pieces.
The body fills in the gap with new bone. It's
a complex surgical technique, but it can predictably generate significant
vertical bone height in the posterior mandible when indicated.
Speaker 1 (15:59):
All right, let's move to the front of the mouth,
the esthetic zone. This is where the pressure is really on.
Isn't it getting not just function but beautiful, natural looking results,
especially dealing with the gums the papilla between teeth.
Speaker 2 (16:11):
Oh. Absolutely, This is arguably the greatest challenge in implant dentistry,
restoring that delicate interplay between the implant crown and the
surrounding soft tissues, making it look like a real tooth.
It requires meticulous planning and execution.
Speaker 1 (16:25):
So what are the biggest factors that predict whether we'll
get a good aesthetic outcome or not.
Speaker 2 (16:30):
Number one, you have to look at the patient's existing
gum tissue type. They're peridonal biotype. Some people have thick,
flat gum tissue it's quite forgiving, doesn't tend to recede easily.
Speaker 1 (16:41):
And the other type, the other.
Speaker 2 (16:42):
Is thin scallop tissue highly prone to recession. If you
make a mistake surgically or prosthetically with this biotype, the
tissue can just shrink away, exposing metal or margins. It's
much higher.
Speaker 1 (16:54):
Risk, So assess the biotype first. What else is absolutely
critical implant positioning.
Speaker 2 (17:00):
This is non negotiable. The implant has to go exactly
where the root of the missing tooth was, not shifted
forward or backward, not tilted randomly. It needs to be
in the correct three dimensional tooth.
Speaker 1 (17:09):
Position, and how deep should it be placed.
Speaker 2 (17:11):
Generally, the top of the implant platform should end up
about three to four milimeters below where the CEJ the
cemented animal junction of the adjacent natural teeth is. That
gives you room for the abutment and the emergence profile
of the crown.
Speaker 1 (17:25):
Okay tooth position three to four millimeter appicle to the
adjacent cujs. What about side to side spacing, especially if
you're replacing two front teeth right next to each other.
Speaker 2 (17:36):
Crucial point to have any chance of getting that little
triangle of gum tissue the papilla to fill the space
between two adjacent implants, you need adequate bone between them.
The rule thumb is a minimum of three, preferably four
millimeters of horizontal bone between the implant platforms.
Speaker 1 (17:52):
So if you place them too close together, you lose.
Speaker 2 (17:54):
The bone peak between them, and the tapillo will inevitably
be flat or missing. A black triangle facing implants in
the inaproximal position. Trying to squeeze them in is an
absolute disaster for esthetics.
Speaker 1 (18:05):
Right now, let's talk about how we attach the crown
cement versus screw retention. You hear a lot of debate,
especially upfront, why is cement such a concern.
Speaker 2 (18:14):
The big fear with cement, particularly when the crown margin
is placed below the gum line for esthetics is excess
cement retention. It's incredibly difficult, maybe impossible, to be certain
you've removed all the excess cement from down to that.
Speaker 1 (18:27):
Sulcus, and leftover cement is bad news.
Speaker 2 (18:30):
Very bad news. It acts like a foreign body irritant.
It's strongly linked to peri implantitis, inflammation and bone loss
around the implant. If that happens, the tissue recedes, the
margin gets exposed. Your beautiful aesthetic result is gone.
Speaker 1 (18:45):
So screw retention is generally safer in that regard.
Speaker 2 (18:48):
Generally, Yes, it avoids the cement issue altogether. Plus it
offers retrievability. If you ever need to take the crown
off from maintenance or repair, you just unscrew it. With
cement removal can be destruct so, especially in the aesthetic zone.
Many clinicians perfer st grew retention if.
Speaker 1 (19:04):
Possible, regardless of how it's retained. That temporary phase seems
important too.
Speaker 2 (19:09):
Oh, absolutely vital. Using a well shaped, anatomically contoured, fixed
provisional crown often for several months, maybe even six months
or longer. That's how you guide the soft tissue healing.
You sculpt the gums, support the papilla, and train the
tissue to sit exactly where you want it before the
final crowd is made. You can't rush that maturation process just.
Speaker 1 (19:30):
Before we wrap up. Maybe touch on a couple of
really specialized situations.
Speaker 2 (19:33):
Good idea. What about patients who've had head and neck
cancer treatment, specifically radiation?
Speaker 1 (19:39):
Right, your radiated tissues pose a significant challenge. Bone that's
received high doses of radiation, say over fifty gray or
five thousand centigray ossio integration is definitely impaired. The blood
supply is compromised.
Speaker 2 (19:51):
So implants might not truly integrate.
Speaker 1 (19:54):
Often the anchorage ends up being more mechanical, sort of
like a tight press fit, rather than true biological fusion.
And because of that, the long term failure rates are
higher and tend to increase over time. It's a high
risk scenario.
Speaker 2 (20:05):
Is there anything that can help?
Speaker 3 (20:06):
Yes?
Speaker 2 (20:07):
Actually, hyperbaric oxygen therapy or HBO, putting the patient in
a high pressure oxygen chamber before and after implant surgery.
It's been shown to significantly improve success rates in irradiated bone.
Speaker 1 (20:19):
How does that work?
Speaker 2 (20:20):
It basically forces more oxygen into the tissues, which promotes angiogenesis,
the formation of new blood vessels. It helps revitalize that
compromised bone and makes integration more likely.
Speaker 1 (20:32):
Interesting. What about the interception of implants and orthodontics.
Speaker 2 (20:35):
That's been a huge development. Implants, or often smaller versions
called minuscrews or tads temporary anchorage devices have become incredibly
valuable tools for orthodontists. Or anchorage exactly absolute anchorage. Unlike teeth,
implants don't move when you pull on them, so orthodontists
can use them as super stable anchor points to achieve
tooth movements that were previously very difficult or unpredictable, things
(20:59):
like intruding mold or pulling front teeth back maximally without
the back teeth drifting forward. It removes the reliance on
patient compliance with things like headgear. It's been a real
game changer.
Speaker 1 (21:09):
And one last area, using just a single implant maybe
to help someone with a partial denture.
Speaker 2 (21:14):
Yeah, that's quite common, especially for patients with lower partial
dentures replacing back teeth what we call Kennedy Class one
or class two arches. They have those free end saddles
with no tooth support at the.
Speaker 1 (21:24):
Very back, which tend to lift up or rock exactly.
Speaker 2 (21:28):
Placing even a single solitary implant underneath the back end
of that denture base can make a world a difference.
It acts as a direct support and often adds some
retention too. It dramatically improves the stability and comfort of
the RPD, especially when.
Speaker 1 (21:43):
Chewing, so it supplements the natural tooth.
Speaker 2 (21:45):
Support precisely, vastly improving function for those patients.
Speaker 1 (21:49):
Wow, Okay, this has been incredibly comprehensive. We've gone from
the molecular level, you know, collagen crosslinking and Perry implant
bone all the way through biomechanics like ap spread and
into these really complex clinical situations like psygomas and a
radiated bone, and.
Speaker 2 (22:05):
Hopefully the connecting threat is clear. Understanding these fundamental principles
the biology, the biomechanics, it's absolutely essential for predictable long
term success. The future really lies in using our modern
tools like CBCT scans and digital planning CADCAM to make
sure every single case is planned backwards from the final restoration.
(22:25):
It has to be proseidontically driven.
Speaker 1 (22:27):
Meaning the desired final tooth position dictates where the implant
must go exactly.
Speaker 2 (22:32):
You start with the end goal and the ideal tooth
setup and then figure out the best surgical way to
get the implant in the perfect spot to support that.
Knowing these fundamentals is just it's non negotiable if you
want consistent results.
Speaker 3 (22:42):
Okay, To help everyone consolidate this, here's a review question
for you listening. You're planning a fixed bridge and FPD.
In the post to your mandible, the patient show signs
of moderate bruxism grinding, and it's a linear gap replacing
the first and second molars. Based on everything we just discussed.
List three critical biomechanical or esthetic futures you absolutely must
build into a treatment plan, and what's the minimum recommended
(23:05):
diameter for those implants. Think back to those rules about
linear setups, load management, bruxism, mullet over apply this knowledge.
Speaker 1 (23:12):
Thanks for joining us on the deep dive.
Welcome to the deep dive today. We are really digging
into something foundational. We've got Volume one of Fundamentals of
Implant Dentistry Proseidontic Principles right here, and our mission, well,
it's pretty intense. Actually, we're going to drill down into
those core biological mechanisms, the clinical strategies, basically everything that
defines modern implant success. So if you're a dental student,
(00:23):
maybe a young professional starting out, or just you know,
really keen on understanding this, feel deeply. We're aiming to
distill every critical concept. We want to show how pretty
much every major clinical decision, whether it's picking an attachment
or even planning something complex like a zygomatic implant, it
all comes back to the biology, the microscopic stuff we're
about to get into.
Speaker 2 (00:43):
Absolutely, and you really can't talk about modern implantology without
going back to that pivotal moment, the nineteen eighty two
Toronto conference that's where per Ingvar Brona Mark introduced osteo
integration change. Everything didn't it completely Yeah, it wasn't just
oh here's a new technique. It was a fund the
mental shift. It basically forced the entire field, especially prostendontics
(01:05):
to put the long term biological health of those tissues
around the implant first and foremost. That set the stage
for everything in this book.
Speaker 1 (01:13):
Okay, so let's unpack that biological basis because long term success,
it's not really about the titanium itself, is it. It's
about how the body responds.
Speaker 2 (01:22):
Precisely, it's the host response. We know ossio integration means
bone growing directly onto the implant surface. But maybe we
should start with the soft tissues first.
Speaker 1 (01:32):
That critical barrier, right, the biological width. I remember learning
about that for natural teeth. How does it apply here?
Speaker 2 (01:37):
Well, it applies directly. It's that combined height of connective
tissue and junctional epithelium just above the bone crest. For implants,
it averages around three millimeters.
Speaker 1 (01:46):
Okay, three milimeter. That's a bit more than the roughly
two milimeter for natural teeth, isn't.
Speaker 2 (01:50):
It slightly more? Yes? And that extra millimeter or the
whole three milimeter, really it matters hugely, especially upfront in
the esthetic zone. Why because the level of the bone
underneath that dictates where your gums are going to sit
the contour.
Speaker 1 (02:05):
So mess with that three millimeter space and you're looking
at potential recession or bone loss down the line.
Speaker 2 (02:10):
Exactly, you have to respect it. It's fundamental. The bone
crest position controls the gum line, simple as that.
Speaker 1 (02:16):
Okay, bone controls the soft tissue contour. Now let's shift
to the hard tissue. That implant surface. It's not just passive, right,
it's doing something.
Speaker 2 (02:25):
Oh, definitely, the texture is key. Nowadays we mostly use
moderately rough titanium surfaces, and the research is clear these
surfaces are excellent at getting platelets activated and forming a
really strong fibrine clot.
Speaker 1 (02:37):
And that clot is the scaffolding for healing.
Speaker 2 (02:39):
Right, It's the essential first step. It kick starts the
whole healing cascade. What's kind of fascinating, though, is that
in other areas like vascular stents, which also use similar surfaces,
they actually want to reduce platelet sticking.
Speaker 1 (02:51):
Huh. So the same surface does opposite things depending on
where it is in the body.
Speaker 2 (02:56):
Exactly. It tells you the bone environment has a very specific,
complex reaction. But for us in implant dentistry, that moderate
roughness is absolutely critical for good initial healing.
Speaker 1 (03:06):
All right, Now, here's where I think it gets really
really interesting. The actual bone that forms around the implant.
It's not just any old bone, is it.
Speaker 2 (03:13):
No, it's quite unique. The bone that forms right up
against the implant surface. This happens through a process called
contact osteogenesis. It actually shows higher levels of specific enzymes
involved in collagen cross linking. We're talking in things like
P four H and CR tap okay, hold.
Speaker 1 (03:29):
On P four h crt app. So translating that, does
it mean the bone being formed is like tougher, stiffer,
more like cortical bone.
Speaker 2 (03:39):
That's a great way to put it. It's creating this
really robust, stiff shell right around the implant, and that's
why it holds up so well long term under chewing forces.
This specialized bone resists the normal breakdown process, the catabolic
remodeling that usually gets rid of weaker woven bone form
during initial healing.
Speaker 1 (03:54):
So it's built to last from the start pretty much.
Speaker 2 (03:57):
And this understanding actually led us to question and older measurement.
We relied on heavily bic or bone to implant contact.
Speaker 1 (04:05):
Right just measuring how much surface area was touching bone exactly.
Speaker 2 (04:08):
We used to think higher bic automatically meant stronger but
then studies came out showing that moderately rough implants compared
to smooth ones might have similar BIC percentages. Okay, but
the rough implants had three times the sheer strength, three
times the resistance to being pulled out sideways.
Speaker 1 (04:25):
Wow. So it's not just about touching, it's about the
quality of.
Speaker 2 (04:28):
The grip precisely. It suggests there's actual biological bonding happening
at that interface, maybe involving specific molecules. Some people think
TYPEX collagen like you see in cartilage development. It's a
bond much stronger than just simple physical contact.
Speaker 1 (04:42):
Okay, let's shift gears from the micro level to the
bigger clinical picture, the fully identialist mandible. That's often cited
as one of the biggest challenges, right, mostly because of
bone loss.
Speaker 2 (04:52):
Oh, it's a major headache. The bone resorption is aggressive.
Most of it happens really fast in the first say,
six to eight months after teeth are lost, but then
it just keeps going slower maybe but continuously throughout life.
Speaker 1 (05:06):
And it's not just random, is it? There might be
a genetic component.
Speaker 2 (05:09):
There seems to be. Some pile studies are starting to
link specific genetic markers smps single nucleotide polymorphisms in a
gene called fgf R one op two. What are three
point zero to really severe mandibular atrophy SMP?
Speaker 1 (05:22):
So tiny variations in DNA. You're saying some people might
just be genetically programmed for more severe bone loss.
Speaker 2 (05:28):
That's the implication. Yeah, imagine a future where we could
do a quick genetic screen and identify patients at super
high risk before they even lose their teeth. That could
totally change how we approach their treatment right from the start.
Speaker 1 (05:39):
Fascinating Now, clinically, how do implants help these patients? Comparing say,
traditional dentures to implant overdentures.
Speaker 2 (05:47):
Well, the studies are interesting. Implant retained over dentures or
iods didn't necessarily lead to massive improvements in overall nutrition
compared to good conventional dentures CDs.
Speaker 1 (05:57):
Oh I would have expected a bigger difference me too.
Speaker 2 (06:00):
Initially, but what they did show was significantly better showing performance,
especially for patients who already had severely resorbed mandibles. They
could just process food much more effectively. Even if their
diet choices didn't drastically change, they felt like they could
eat better.
Speaker 1 (06:16):
Makes sense, so when we opt for an iod maybe one,
using just two implants up front with something like a
hater bar, how does that design work biomechanically? How does
it protect those implants?
Speaker 2 (06:28):
Ah? The hater bar clip system is a classic implant
assisted over denser. The keyword is assisted. It's clever because
it shares the load. The denture can actually rotate slightly
around the bar when the patient bites down on the
back teeth.
Speaker 1 (06:41):
Okay, so it pivots exactly.
Speaker 2 (06:43):
So the implants handle the forces in the front, but
the main chewing load in the back still gets distributed
onto the patient's own tissues, the buckle shelf area, the
retromolar pads. This sharing minimizes twifting or torquing forces on
those front implants, which is really crucial for their long
term survival, especially with just two.
Speaker 1 (07:00):
Right now, what if we go for a fully fixed solution,
the classic Brona Mark style fixed hybrid prosthesis. What are
the absolute must follow rules there? Biomechanically?
Speaker 2 (07:13):
Load management becomes even more critical. Two numbers are key. First,
your ap spread. That's the distance from the center of
the most forward implant to the center of the most
backward implant on one side.
Speaker 1 (07:24):
Anteroposterior spread.
Speaker 2 (07:25):
Got it. That AP spread needs to be at least
one centimeter minimum second. Any candilever, the part of the
bridge extending backward past the last mplant generally shouldn't be
more than two times that AP spread, and usually there's
an absolute max limit, maybe around twenty milimeters, regardless of
the spread.
Speaker 1 (07:42):
It's like wheelbase on a car, isn't it. You need
a decent wheelbase AP spread before you can safely hang
much weight off the back cantilever. A short wheelbase with
a long overhang is just asking for trouble.
Speaker 2 (07:53):
That's a perfect analogy spot on And another critical point
anatomically trying to place implants way back post steerity to
the mental forum and in a fully identialist mandible, it's
usually not needed, and it's actually risky. Why risky Because
a mandible flexes. It actually bends inwards when you clench hard,
sometimes up to a full millimeter in the moldar.
Speaker 1 (08:13):
Region a millimeter wow.
Speaker 2 (08:14):
Yeah, And that much movement means you absolutely cannot rigidly
splint implants across that bending zone. It creates huge stresses,
so you generally stop implants just in front of the
mental forum.
Speaker 1 (08:26):
And the materials for these fixed bridges have evolved too, right, Oh, definitely.
Speaker 2 (08:30):
The original hybrids were acrylic teeth processed onto a metal bar.
They worked, but the acrylic wears it can stain, its
porous hygiene can be tough. Now we're seeing a big
shift towards metal ceramic options or even full monolithic zirconia.
They look great, they're superware resistant and much easier to
keep clean because they're non porous. Okay, shifting upstairs to
(08:51):
the maxilla, totally different ballgame here. The bone tends to
resorb inwards from the cheek side towards the palate lebiobucle
to lingle and.
Speaker 1 (09:00):
Creates problems, doesn't it.
Speaker 2 (09:01):
It often leads to what looks like a Class three
jaw relationship, even if the patient wasn't originally Class three.
The upper jaw just collapses inwards. This means you often
need a flange that pink part of the denture to
provide lip support and restore the facial profile.
Speaker 1 (09:16):
Which often makes an overdensure a better choice than fixed,
especially for older folks.
Speaker 2 (09:21):
Exactly, over dentures are often highly favored in the maxilla
for that reason. Restoring lost tishoe volume and lip support.
Speaker 1 (09:27):
And honestly, quite often a conventional maxillary denture works really well.
Doesn't it much better than a lower one? Usually?
Speaker 2 (09:34):
Absolutely, you've got the whole palette for suction that peripheral
col You generally have a broader base of support, and
the bone resorption is typically slower and less severe than
in the mandible. So often a well made conventional upper
dentsure is perfectly adequate.
Speaker 1 (09:50):
So when do we really need implants in the maxilla?
What pushes us towards that?
Speaker 2 (09:56):
Well, sometimes it's patient demand. They just hate having their
palate covered. Psychologically they want it open. That's big driver.
Or sometimes the retention fails even with a good venture base,
usually because of severely dry mouse maybe from stogrin syndrome
or head of neck radiation. If you can't get that
peripheral seal because there's no saliva, implants might be the
(10:17):
only way to get.
Speaker 1 (10:17):
Stability and biomechanically. You mentioned the bone up there is
usually weaker, poorer quality.
Speaker 2 (10:23):
Generally, yes, often type three or even type four bone.
It's just not as dense as the typical lower jawbone,
and often there's less quantity too, especially vertically.
Speaker 1 (10:33):
So what does that mean for planning?
Speaker 2 (10:35):
It means you have to over engineer things. You can't
cut corners. For a fixed prosthesis in the maxilla, the
recommendation is usually a minimum of six implants well spread
out actually aligned if possible, and you need a good
apiece spread at least two centimeters this time.
Speaker 1 (10:49):
Six implants two centimeters eight piece bread minimum for fixed
Got it?
Speaker 2 (10:53):
What if there just isn't enough bone for standard placement.
Speaker 1 (10:56):
That's where we get into more advanced techniques for the
really resorbed maxilla. One option is using angled implants like
in the all on four concept, or even trans sinus implants.
Speaker 2 (11:05):
How do angled implants help? By tilting the postcuar implants,
you can use longer implants, maybe fifty percent longer, because
you're engaging denser bone often found near the floor of
the sinus or the pure form rim further forward. This
also helps achieve that crucial apiece spread without extensive grafting.
Speaker 1 (11:22):
And if even that's not enough, if the atrophy is extreme.
Speaker 2 (11:25):
Then you might consider zygomatic implants. These are very long
implants that bypass the maxilla entirely and anchor directly into
the zygoma the cheekbone.
Speaker 1 (11:34):
Wow, that sounds complex.
Speaker 2 (11:36):
It is. It's very demanding surgery requires specialized training, but
the success rates are actually quite high and it can
be a fantastic alternative to massive bone grafting procedures in
severely a trophic cases.
Speaker 1 (11:48):
Okay, let's zoom in again, this time to partially addentialist cases. Specifically,
the posterior area is replacing molars or premolars. Here, the
implants often end up in a straight line, right exactly.
Speaker 2 (11:59):
You usually just fill a gap between existing teeth. That
linear arrangement is the big biomechanical challenge back there.
Speaker 1 (12:05):
Why is it such a challenge Because you.
Speaker 2 (12:07):
Lose that Crosshart stabilization you get in a full arch
case imagine trying to balance on a tightrope versus standing
with your feet apart. The linear setup is much less
stable against forces that aren't straight down the long axis
of the implant's lateral forces. Twisting forces, so.
Speaker 1 (12:23):
More vulnerable to sideloads.
Speaker 2 (12:25):
Extremely vulnerable. And that's why the number one rule for
fixed partial dentures fpds supported by implants in the posterior
is no cantilevers. Period. Don't hang a tooth off the
end of the last implant, it puts tremendous stress on
that implant and the components.
Speaker 1 (12:40):
Okay, no cantilevers non negotiable. How do we decide how
many implants to use them and how big should they be?
Speaker 2 (12:47):
Well, for a typical gap, say replacing two premolars in
a first molear a three unit FPD in the mandible
where bone is usually good, two implants are often enough,
one at each hand.
Speaker 1 (12:57):
But what about trickier situations.
Speaker 2 (12:59):
Right if you're replacing say four units, or if you
have to use shorter implants maybe less than ten millimeters long,
or if you know the patient grinds heavily bruxism or
has a really strong bite like a brachycephalic facial.
Speaker 1 (13:11):
Type, square jaw, heavy muscles.
Speaker 2 (13:13):
Exactly in those cases, adding a third implant in the
middle is a very wise move. It just distributes the
load much better. And in terms of size, you want
robust implants back there. Never go too narrow. The recommendation
is generally at least four point zero millimeters in diameter
to minimize the risk of the implant itself fracturing under
heavy chewing forces.
Speaker 1 (13:33):
Okay, robust implants, maybe add an extra one for heavy loads.
Since those lateral forces are the enemy. How do we
design the chewing surfaces the occlusion on the crowns.
Speaker 2 (13:44):
The absolute goal is to minimize any sideways forces hitting
the implants. So if the patient already shows signs of
wear on their natural teeth suggesting they might grind or clench,
then a mutually protected occlusion is generally preferred.
Speaker 1 (13:58):
Meaning the front teeth guide the jaw during sideways movements,
discluding the.
Speaker 2 (14:01):
Back teeth precisely. The anterior guidance protects the postery implants. Now,
if there are no obvious signs of problematic occlusion, then
group function where multiple teeth share the load during side
movements might be acceptable.
Speaker 1 (14:14):
And the shape of the faked teeth themselves, you have.
Speaker 2 (14:16):
To be smart about the design. Narrow the chewing table,
don't make the implant crown as wide as a natural molar,
keep the cusp angles shallow, not steep and pointy, and
critically make sure the main contact points during chewing are
centered right over the long axis of the implant body.
Speaker 1 (14:33):
How do you achieve that centering.
Speaker 2 (14:35):
Clinically for lower fpds that often means a lingualized contact
scheme for upper fpds, it might be more buccalized. You're
basically shifting the main force vector inwards or outwards slightly
to line up with the implant underneath.
Speaker 1 (14:49):
Makes sense. Now, what if the site isn't ideal, not
enough bone height, especially in the upper posterior over the sinus,
or maybe not enough width anywhere.
Speaker 2 (14:58):
Site deficiencies are common for vertical height problems in the
maxilla sinus augmentation, lifting the sinus membrane and placing bone
graph material is a very predictable procedure, lots of long
term data on that.
Speaker 1 (15:10):
But what about vertically in the mandible, especially back near the.
Speaker 2 (15:12):
Nerve AH, that's much trickier. Trying to gain vertical bone
height on top of the ridge over the inferior alveolar
nerve using traditional bone graphs is generally quite unpredictable and
carries risks to the nerve. It's not something done routinely.
Speaker 1 (15:27):
So if you need more height there, if.
Speaker 2 (15:29):
You have at least say four to five millimeters of
existing bone above the nerve canal, then distraction osciogenesis becomes
a viable option.
Speaker 1 (15:37):
Distraction that's where you cut the bone and slowly pull
the segments apart exactly.
Speaker 2 (15:41):
You make a surgical cut, attach a device, and then slowly,
fraction of a millimeter per day, you separate the two pieces.
The body fills in the gap with new bone. It's
a complex surgical technique, but it can predictably generate significant
vertical bone height in the posterior mandible when indicated.
Speaker 1 (15:59):
All right, let's move to the front of the mouth,
the esthetic zone. This is where the pressure is really on.
Isn't it getting not just function but beautiful, natural looking results,
especially dealing with the gums the papilla between teeth.
Speaker 2 (16:11):
Oh. Absolutely, This is arguably the greatest challenge in implant dentistry,
restoring that delicate interplay between the implant crown and the
surrounding soft tissues, making it look like a real tooth.
It requires meticulous planning and execution.
Speaker 1 (16:25):
So what are the biggest factors that predict whether we'll
get a good aesthetic outcome or not.
Speaker 2 (16:30):
Number one, you have to look at the patient's existing
gum tissue type. They're peridonal biotype. Some people have thick,
flat gum tissue it's quite forgiving, doesn't tend to recede easily.
Speaker 1 (16:41):
And the other type, the other.
Speaker 2 (16:42):
Is thin scallop tissue highly prone to recession. If you
make a mistake surgically or prosthetically with this biotype, the
tissue can just shrink away, exposing metal or margins. It's
much higher.
Speaker 1 (16:54):
Risk, So assess the biotype first. What else is absolutely
critical implant positioning.
Speaker 2 (17:00):
This is non negotiable. The implant has to go exactly
where the root of the missing tooth was, not shifted
forward or backward, not tilted randomly. It needs to be
in the correct three dimensional tooth.
Speaker 1 (17:09):
Position, and how deep should it be placed.
Speaker 2 (17:11):
Generally, the top of the implant platform should end up
about three to four milimeters below where the CEJ the
cemented animal junction of the adjacent natural teeth is. That
gives you room for the abutment and the emergence profile
of the crown.
Speaker 1 (17:25):
Okay tooth position three to four millimeter appicle to the
adjacent cujs. What about side to side spacing, especially if
you're replacing two front teeth right next to each other.
Speaker 2 (17:36):
Crucial point to have any chance of getting that little
triangle of gum tissue the papilla to fill the space
between two adjacent implants, you need adequate bone between them.
The rule thumb is a minimum of three, preferably four
millimeters of horizontal bone between the implant platforms.
Speaker 1 (17:52):
So if you place them too close together, you lose.
Speaker 2 (17:54):
The bone peak between them, and the tapillo will inevitably
be flat or missing. A black triangle facing implants in
the inaproximal position. Trying to squeeze them in is an
absolute disaster for esthetics.
Speaker 1 (18:05):
Right now, let's talk about how we attach the crown
cement versus screw retention. You hear a lot of debate,
especially upfront, why is cement such a concern.
Speaker 2 (18:14):
The big fear with cement, particularly when the crown margin
is placed below the gum line for esthetics is excess
cement retention. It's incredibly difficult, maybe impossible, to be certain
you've removed all the excess cement from down to that.
Speaker 1 (18:27):
Sulcus, and leftover cement is bad news.
Speaker 2 (18:30):
Very bad news. It acts like a foreign body irritant.
It's strongly linked to peri implantitis, inflammation and bone loss
around the implant. If that happens, the tissue recedes, the
margin gets exposed. Your beautiful aesthetic result is gone.
Speaker 1 (18:45):
So screw retention is generally safer in that regard.
Speaker 2 (18:48):
Generally, Yes, it avoids the cement issue altogether. Plus it
offers retrievability. If you ever need to take the crown
off from maintenance or repair, you just unscrew it. With
cement removal can be destruct so, especially in the aesthetic zone.
Many clinicians perfer st grew retention if.
Speaker 1 (19:04):
Possible, regardless of how it's retained. That temporary phase seems
important too.
Speaker 2 (19:09):
Oh, absolutely vital. Using a well shaped, anatomically contoured, fixed
provisional crown often for several months, maybe even six months
or longer. That's how you guide the soft tissue healing.
You sculpt the gums, support the papilla, and train the
tissue to sit exactly where you want it before the
final crowd is made. You can't rush that maturation process just.
Speaker 1 (19:30):
Before we wrap up. Maybe touch on a couple of
really specialized situations.
Speaker 2 (19:33):
Good idea. What about patients who've had head and neck
cancer treatment, specifically radiation?
Speaker 1 (19:39):
Right, your radiated tissues pose a significant challenge. Bone that's
received high doses of radiation, say over fifty gray or
five thousand centigray ossio integration is definitely impaired. The blood
supply is compromised.
Speaker 2 (19:51):
So implants might not truly integrate.
Speaker 1 (19:54):
Often the anchorage ends up being more mechanical, sort of
like a tight press fit, rather than true biological fusion.
And because of that, the long term failure rates are
higher and tend to increase over time. It's a high
risk scenario.
Speaker 2 (20:05):
Is there anything that can help?
Speaker 3 (20:06):
Yes?
Speaker 2 (20:07):
Actually, hyperbaric oxygen therapy or HBO, putting the patient in
a high pressure oxygen chamber before and after implant surgery.
It's been shown to significantly improve success rates in irradiated bone.
Speaker 1 (20:19):
How does that work?
Speaker 2 (20:20):
It basically forces more oxygen into the tissues, which promotes angiogenesis,
the formation of new blood vessels. It helps revitalize that
compromised bone and makes integration more likely.
Speaker 1 (20:32):
Interesting. What about the interception of implants and orthodontics.
Speaker 2 (20:35):
That's been a huge development. Implants, or often smaller versions
called minuscrews or tads temporary anchorage devices have become incredibly
valuable tools for orthodontists. Or anchorage exactly absolute anchorage. Unlike teeth,
implants don't move when you pull on them, so orthodontists
can use them as super stable anchor points to achieve
tooth movements that were previously very difficult or unpredictable, things
(20:59):
like intruding mold or pulling front teeth back maximally without
the back teeth drifting forward. It removes the reliance on
patient compliance with things like headgear. It's been a real
game changer.
Speaker 1 (21:09):
And one last area, using just a single implant maybe
to help someone with a partial denture.
Speaker 2 (21:14):
Yeah, that's quite common, especially for patients with lower partial
dentures replacing back teeth what we call Kennedy Class one
or class two arches. They have those free end saddles
with no tooth support at the.
Speaker 1 (21:24):
Very back, which tend to lift up or rock exactly.
Speaker 2 (21:28):
Placing even a single solitary implant underneath the back end
of that denture base can make a world a difference.
It acts as a direct support and often adds some
retention too. It dramatically improves the stability and comfort of
the RPD, especially when.
Speaker 1 (21:43):
Chewing, so it supplements the natural tooth.
Speaker 2 (21:45):
Support precisely, vastly improving function for those patients.
Speaker 1 (21:49):
Wow, Okay, this has been incredibly comprehensive. We've gone from
the molecular level, you know, collagen crosslinking and Perry implant
bone all the way through biomechanics like ap spread and
into these really complex clinical situations like psygomas and a
radiated bone, and.
Speaker 2 (22:05):
Hopefully the connecting threat is clear. Understanding these fundamental principles
the biology, the biomechanics, it's absolutely essential for predictable long
term success. The future really lies in using our modern
tools like CBCT scans and digital planning CADCAM to make
sure every single case is planned backwards from the final restoration.
(22:25):
It has to be proseidontically driven.
Speaker 1 (22:27):
Meaning the desired final tooth position dictates where the implant
must go exactly.
Speaker 2 (22:32):
You start with the end goal and the ideal tooth
setup and then figure out the best surgical way to
get the implant in the perfect spot to support that.
Knowing these fundamentals is just it's non negotiable if you
want consistent results.
Speaker 3 (22:42):
Okay, To help everyone consolidate this, here's a review question
for you listening. You're planning a fixed bridge and FPD.
In the post to your mandible, the patient show signs
of moderate bruxism grinding, and it's a linear gap replacing
the first and second molars. Based on everything we just discussed.
List three critical biomechanical or esthetic futures you absolutely must
build into a treatment plan, and what's the minimum recommended
(23:05):
diameter for those implants. Think back to those rules about
linear setups, load management, bruxism, mullet over apply this knowledge.
Speaker 1 (23:12):
Thanks for joining us on the deep dive.
Popular Podcasts
CrimeLess: Hillbilly Heist
It’s 1996 in rural North Carolina, and an oddball crew makes history when they pull off America’s third largest cash heist. But it’s all downhill from there. Join host Johnny Knoxville as he unspools a wild and woolly tale about a group of regular ‘ol folks who risked it all for a chance at a better life. CrimeLess: Hillbilly Heist answers the question: what would you do with 17.3 million dollars? The answer includes diamond rings, mansions, velvet Elvis paintings, plus a run for the border, murder-for-hire-plots, and FBI busts.
Crime Junkie
Does hearing about a true crime case always leave you scouring the internet for the truth behind the story? Dive into your next mystery with Crime Junkie. Every Monday, join your host Ashley Flowers as she unravels all the details of infamous and underreported true crime cases with her best friend Brit Prawat. From cold cases to missing persons and heroes in our community who seek justice, Crime Junkie is your destination for theories and stories you won’t hear anywhere else. Whether you're a seasoned true crime enthusiast or new to the genre, you'll find yourself on the edge of your seat awaiting a new episode every Monday. If you can never get enough true crime... Congratulations, you’ve found your people. Follow to join a community of Crime Junkies! Crime Junkie is presented by audiochuck Media Company.
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.