Something that he termed the micro pump

something that he termed the micro pump

and the micro pump was related to the

amount of space and a vacuum that space

caused on an implant and so if we have a

lot of space inside our implant that the

parts don’t fit right and there’s just a

lot of gap when you chew back and forth

that lateral movement will open up a

micro gap and then micro pump or vacuum

will force fluid saliva bacteria into

your implant and have a nice little home

for that implant – or within that

implant for that bacteria so when

designing the ideal implant we want an

implant that does not have much of a

micro gap and certainly does not have a

lot of space in between the implant

components I apologize my last

presentation had a really cool video so

you’ll have to use your imagination here

which is really not something you want

to do in a lecture but on the left-hand

side we have a very platform switched

implant that has a conical connection

and when chewing laterally on this

implant there’s really little micro

movement at all on the right hand side

we have an old-school implant that

certainly has a lot of space underneath

it and has sort of an external bevel and

that one had quite a bit of space

so why screw loosing bad so this is not

my patient on the image below but I tell

you that kind of presentation that very

puffy and very angry looking gingiva

around a loosened abutment screw is very

common and very scary I’ve placed

implants and done immediate

temporization only to have my temporary

loosen up and I’ll see something like

that and immediately think oh my god I

lost the and when we look at screw

loosening in general as long as we

torque our abutment screws down to the

proper amount of torque with the implant

system I use that’s 30 Newton

centimeters of torque I like to use a

multi torque wrench that you see above

the average amount of screw loosening in

modern implants is about six percent

that’s not a really big amount however

an external hex implants that we use

before they can be up to 57 percent of

screw rule fitting but hey what happens

when you have a screw loosen and this is

a bigger discussion it’s certainly a

topic for another webinar or a class

I’ve really moved from doing a lot of

cemented restorations to retain

restorations and so if you have in a

button that happens to loosen up the

first little game you’re going to play

is find the abutment screw if you’re

really really good and always put your

implant in the center of the attention

of space it should be easy to find and

if it’s not you can always look at your

x-ray and see where that is but in

essence what you do is you cut a hole

through the crown into the abutment and

make yourself a quote unquote screw

mental restoration so go ahead and pop

that out play some teflon tape of I use

a combination of two types of composites

I really like flow at ALC from premiere

as my flowable composite you can see how

opaque that is

a taste composite over the top this is

24 biker which I have the opaque version

the name of the game in filling access

fees on to routine crowns or if you’re

doing a screw mental restoration is you

know making sure that you pack enough

teflon tape to will pick that out we

talked about screw loosening a lot but

my Vain’s existence as a restorative

dentist is group breakage and lucky I’m

lucky in that I haven’t seen a lot of

broken screws in my day but when you do

have a broken screw it’s certainly

something you want to avoid and again

the topic today is the abutment

connections we’ll talk about avoiding

this in the first place but this real

quick let’s talk about what happened so

this patient came in I had done a

titanium base with a ceramic screw

retain restoration on top I use this

type of tool there’s different names for

it

implant direct calls it the X s XP and

no that’s not something that teenagers

do with their phones the FX T stands or

screw extraction tool it’s fun clockwise

and as its goes in clockwise it backs

out the screw and as a side note I like

to always use the abutment screws that

come with my implants the native

abutment screw and implant direct we get

a free screw that comes with it however

if you’re using a different company you

may want to buy the abutment screw that

is native to the implant that you’re

using rather than abutment screws that

may be provided by your lab or the

connections we’ll talk about avoiding

this in the first place but this real

quick let’s talk about what happened so

this patient came in I had done a

titanium base with a ceramic screw

retain restoration on top I use this

type of tool there’s different names for

it

implant direct calls it the X s XP and

no that’s not something that teenagers

do with their phones the FX T stands or

screw extraction tool it’s fun clockwise

and as its goes in clockwise it backs

out the screw and as a side note I like

to always use the abutment screws that

come with my implants the native

abutment screw and implant direct we get

a free screw that comes with it however

if you’re using a different company you

may want to buy the abutment screw that

is native to the implant that you’re

using rather than abutment screws that

may be provided by your lab or the

on the Nobel replaced implants and

there’s certainly a lot of companies

that have tri lobe implants trial of

implants or how I got started in

planetology so the surgeon who is

placing implants and I was restoring

them used a tri low type implant and I

thought hey when I started placing

implants I kind of liked it I’m going to

go ahead and start I moved on later on

to an internal hex type implant and

later to the conical connection one

thing that’s great about tri lobe type

implants is they’re very very easy to

restore because the abutment only goes

in three ways hex type implants do have

variations and how you can restore it

especially if you have multiple implants

and multiple abutments that can become a

little problematic

um so more is not necessarily better to

take it one step further a lot of

conical connection type implants do have

hexes within them so there is an anti

rotational feature it’s just deeper into

the implant itself but for the sake of

this discussion in sort of my personal

experience will be discussing the

implants I have used the legacy and

from implant erectus one that I have one

variation on some internal axis is that

it has what’s called a 45-degree lead in

bevel and what that means is it’s kind

of a conical connection in that is sunk

into the implant and there is some

degree of angulation in that area that

is inside the inlet now a conical

connection implant has a very large

amount of ferrule or internal service

and that angulation is quite a bit

steeper than 45 degrees if you look at

sort of implant companies and implant

research one thing that’s nice is that

implant companies kind of I don’t want

to say copy off of each other but

there’s certainly dominant trends that

we see in implantology flap or external

hex pipe implants don’t have a lot of

internal ferrule or internal contact

between the sort of male portion of the

abutment and the internal connection

before you five-degree lead in bevel

internal x implants as you can see in

the size of the abutment the gold

portion on that zirconia is we got a

little bit more

however we go to a conical connection

type implant there is just quite a bit

of internal barrel or internal surface

area between the abutments and um there

is some disagreement on how you measure

the degree of internal connection that

we have some people measure it from the

outside so you might hear a conical

connection having a 10 degree or a 15

degree some measure from the inside so

for the sake of this discussion I’ll be

measuring it from the inside

so a butt joint type implant

um really has no degree of internal

ferrule there’s sort of a portion the

guys to screw but we don’t really have

much of an emulation between the flat

surface and the inside so some may even

say that’s a 90 degree butt joint but

for the sake of this discussion let’s

just say that it is the internal hex

implant has a 45 degree lead in bevel

the conical connection type implant that

would we’ll be discussing today the

interactive from implant direct as

almost an 80 degree internal bevel and

there’s internal octagon type implants

that are compatible with Stralman that

is more of a more paper or a much deeper

internal connection which is 82 degrees

so why do we here why do we care what

type of internal connection that we’re

placing well again as mentioned earlier

surgically your restorative lis the name

of the game is to place an implant

that’s going to stay there forever we

want to minimize the amount of bone loss

that we have around our implant and it

stayed before and we know this in pareo

that if the patient comes in with tartar

all over their teeth and pleural hygiene

we’ll see inflammation of the gingiva or

gingivitis that sustained inflammation

will lead to periodontitis so if we have

an implant obviously we don’t have a

periodontal we can’t use the same

terminology but if we have localized

inflammation around the top of our

implant or implant platform that

sustained inflammation will lead to bone

loss over time so let’s talk about how

abutments connect with the rest of the

implant so the external Hecker implant

or the internal Trollope are described

as flat on flat connections and if you

look at the image to the right you can

see that external hacks is really a butt

joint with the connection inside the

implant and if you look the image

left you can see – there’s really no

degree of paper between that sort of

mail portion of the abutment and the

internal connection as a result you

really got to sort of open up the inside

of the implant to allow these to clear

imagine having a crown press and your

crown prep has a zero degree of table

any casting problem or problem with the

lab will prevent that crown from seating

so as a result you’re going to need more

die spacer and implants with a flat on

flat connection they typically have a

large amount of space inside the implant

and that turns into a micro pump as the

tooth people – laterally more and more

saliva and bacteria will be pumped into

the inside of the implant and this is

just sort of shows you the difference

between the two now one thing that’s

very interesting and we’ll talk a little

bit about tactile feel when using a a

conical connection because there’s such

a large amount of the abutment that sits

inside as you torque the abutment down

there is a sort of spreading effect

between that conical can or the conical

connection and the internal part of the

abutment and the abutment will actually

spread the implant laterally that gives

us quite a bit of cold welding and

further prevents any sort of micro

movements on the impact one side note

which is an interesting thing that

certainly has happened to me which is no

fun at all but when you’re using and a

tri lobe type implant sometimes those

points of the hex

the high pain can get very thin around

those areas and implant direct is

certainly has taken

measures to bolster or thicken the

amount of implant material around these

try loads but I’m sure there’s a lot of

people out there who have had to deal

with implant flowering and again that’s

certainly not a fun thing to do

interesting enough reading the zipper

study I remember some of the first trial

of type implants I would take off the

abutment screw or maybe if I put on a

temporary abutment it was ready to

restore he would take them off and you

know dang it would be really really

smelly in there and so back to dr.

zebras analogy of the galoshes and being

in water you’re just getting all sorts

of yucky has basically pumped into your

implant internal connection and this is

just an example of taking off an

abutment and seeing that the results of

that micro pump one other interesting

aspect doctor exhibits were looked at

was the amount of micro gap between a

platform shifted implant and a non

platform shifted in and this makes a lot

of sense a platform shifted implant will

display much less of a micro gap then

something that does not and I think that

really just plays hand-in-hand with the

diameter of the implant the amount of

movement you get obviously as you get to

the edges or fringes of a very large

abutment that is going to move just

another image showing the difference

between flat on flat and conical the

take-home message really is that by

minimizing the amount of space inside

the internal connection and also having

this bolstering effect of the implant

pushing laterally onto the internal

connection and sealing things up and

getting cold welding we can minimize

that

as days before this area marked in

orange is the area where the implant

will spread laterally one thing that’s

nice if we have a lot of good bone is

that bone is also going to be pushing

back so as that spreads laterally the

bone will push back and further squeeze

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