Level II: Advanced Implant Placement and Restoration Course Dr. David Dalise Dr. Gary McCabe Ross
Diagnosis and Treatment Planning
Treatment Planning <ul><li>Patient’s desire must be determined  </li></ul><ul><ul><li>Fixed or Removable </li></ul></ul><u...
Comprehensive Stomatognathic Assessment (continued) <ul><li>Health history </li></ul><ul><li>Radiographic Assessment </li>...
Hard Tissue Evaluation <ul><li>Ridge Classifications </li></ul><ul><li>Ridge Angulation </li></ul><ul><li>Bone Density or ...
Partially Edentulous Arch with Bilateral Edentulous Areas Posterior to Remaining Natural Teeth
Partially Edentulous Arch with Bilateral Edentulous Areas Posterior to Remaining Natural Teeth
Partially Edentulous Arch with Bilateral Edentulous Areas Posterior to Remaining Natural Teeth
Partially Edentulous Arch with Bilateral Edentulous Areas Posterior to Remaining Natural Teeth
Partially Edentulous Arch with Bilateral Edentulous Areas Posterior to Remaining Natural Teeth
Partially Edentulous Arch with Unilateral Edentulous Area Posterior to Remaining Teeth
Partially Edentulous Arch with Unilateral Edentulous Area Posterior to Remaining Teeth
Partially Edentulous Arch with Unilateral Edentulous Area with Natural Teeth Remaining Anterior and Posterior
Partially Edentulous Arch with Unilateral Edentulous Area Anterior to Remaining Natural Teeth, and Crosses the Midline
Classification of Completely Edentulous Arches
Classification of Completely Edentulous Arches
Classification of Completely Edentulous Arches
Classification of Completely Edentulous Arches
Classification of Completely Edentulous Arches
Classification of Completely Edentulous Arches
Classification of Completely Edentulous Arches
Classification of Completely Edentulous Arches
Classification of Completely Edentulous Arches
Classification of Completely Edentulous Arches
Classification of Completely Edentulous Arches
Classification of Completely Edentulous Arches
Soft Tissue Evaluation <ul><li>Attached/Keratinized Gingival Tissue </li></ul><ul><li>Unattached/ non-Keratinized Mucosal ...
Occlussal Analysis <ul><li>Jaw relationship/Occlussal classification </li></ul><ul><ul><li>Class I </li></ul></ul><ul><ul>...
Occlussal Analysis <ul><li>Parafunctional analysis </li></ul><ul><ul><li>Bruxism </li></ul></ul><ul><ul><li>Clenching </li...
Systemic Disease <ul><li>Diabetic </li></ul><ul><li>Autoimmune diseases </li></ul><ul><li>Chemotherapy </li></ul><ul><li>I...
Prosthetic Analysis <ul><li>Fixed </li></ul><ul><li>Removable </li></ul><ul><ul><li>Overdenture </li></ul></ul><ul><ul><li...
Implant Placement
Root Form Implants <ul><li>Straight, Non-tapered body </li></ul>
Root Form Implants <ul><li>Tapered Body </li></ul>
Root Form Implants <ul><li>One-Piece Implants </li></ul>
Root Form Implants <ul><li>Short Implants  </li></ul><ul><ul><li>< 8mm </li></ul></ul>
“ Mini” Implants <ul><ul><li>Less than or equal to 3.0mm </li></ul></ul>1.8mm 3.0mm I-Mini
Anatomical Considerations <ul><li>Mandible </li></ul><ul><ul><li>Anterior: Anterior to the mental foramen </li></ul></ul><...
Anatomical Considerations <ul><ul><li>Posterior: distal to the mental foramen </li></ul></ul><ul><ul><ul><li>Anatomical co...
Anatomical Considerations <ul><li>Lekholm and Zarb’s four bone qualities for the anterior region of the jaws: </li></ul><u...
Maxilla <ul><li>Anterior (pre maxilla): anterior to the maxillary sinus </li></ul><ul><ul><li>Radiographic landmarks </li>...
Maxilla <ul><li>Posterior: distal to anterior border of the maxillary sinus extending to maxillary tuberosity. </li></ul><...
Surgical Considerations <ul><li>Access Assessment </li></ul><ul><ul><li>This is critical in determining the ability to pla...
Surgical Considerations <ul><li>Flap </li></ul><ul><ul><li>Indications/Advantages </li></ul></ul><ul><ul><ul><li>Unaccepta...
Flap (continued) <ul><ul><li>Design </li></ul></ul><ul><ul><ul><li>Considerations for proper access to osteotomy site </li...
Flap, Anatomical Considerations (continued) <ul><ul><ul><li>Neurological – Be aware of location of nerve bundles prior to ...
Single Tooth Esthetic Zone (preop) Incisal View
Single Tooth Esthetic Zone (preop) Labial View
Papillae Saving Incision
Extension to Lingual
Tissue Flap Release
Flap Release Continued
Initiation of Osteotomy Utilizing Osteotomes
Implant Placed with Cover Screw
Primary Closure
Flapless Surgery <ul><ul><li>Indications/Advantages </li></ul></ul><ul><ul><ul><li>Well documented, adequate bone height a...
Flapless Surgery <ul><ul><li>Methodology </li></ul></ul><ul><ul><ul><li>Anesthetize patient appropriately for procedure </...
Flapless Surgery <ul><ul><li>Armamentarium </li></ul></ul><ul><ul><ul><li>Surgical Stent </li></ul></ul></ul><ul><ul><ul><...
Case Example # 2 Pre Operative
Pre Operative Ridge
Pre Operative Ridge Occlusal View
Acrylic Stent in Place
Marking Ridge Utilizing Acrylic Stent
Marking Ridge Utilizing Acrylic Stent
Osteotomy Sites Marked On Ridge
Tissue Punch Pre Osteotomy
Appearance of Ridge Following Initial Use of Tissue Punch
Removal of Tissue Plug and Initiation of Pilot Hole (#8 Bur)
Appearance of Ridge Following Removal of Tissue Plug
Appearance of Ridge Following Removal of Tissue Plug
Pilot Drill – Initial Osteotomy
Flapped to Expose Bone Fixation Screws for Removal Prior to Implant Placement
Bone Fixation Screw
Occlusal View
Removal of Fixation Screw
Ligated Paralleling Pin
Ligated Paralleling Pins
Implant Placement with Handpiece
Implant Placement with Handpiece
Implant Placement with Handpiece
Implant Placement with Handpiece
Implant Placement with Handpiece Implant Seated to Proper Depth
Implant Placement with Handpiece Implant Seated to Proper Depth
Implant Placement Prior to Soft Tissue Closure
Placement of Healing Abutments/Temporary Abutments
Occlusal View
Flap Closure
Flap Closure
Flap Closure
Final Occlusal View
Temporary Abutments Prepared for Use with Temporaries
Temporary Stent in Place Over Implants
Finalizing Reduction of Temporary Abutments
Obturation of Abutment Access
Use of Tempit Light Cure to Close Access Hole
Prefabricated Silicone Temporary Stent
Temporary Stent with BIS-Acrylic Temporary Material in Place
Immediate Post Operative Temporization
Osteotomies <ul><li>Mark intended location of entry point </li></ul><ul><li>Pilot hole </li></ul><ul><li>Alignment verific...
Implant Placement <ul><li>Delivery to osteotomy </li></ul><ul><ul><li>Hand Placement  </li></ul></ul><ul><ul><li>Rotary Ha...
Implant Placement <ul><li>Revisions </li></ul><ul><ul><li>Realignment of osteotomy </li></ul></ul><ul><ul><ul><li>Correct ...
Immediate Post Placement Options <ul><li>Two-stage option </li></ul><ul><ul><li>Place cover screw and close it; flap was u...
Immediate Post Placement Options <ul><li>One stage option </li></ul><ul><ul><li>Place healing abutment </li></ul></ul><ul>...
One Piece Implants <ul><li>Why? </li></ul><ul><ul><li>Strongest </li></ul></ul><ul><ul><li>Eliminate abutment/implant inte...
One Piece Implants <ul><li>Temporization options </li></ul><ul><ul><li>Adaptation to pre existing prosthetics </li></ul></...
Implant Loading <ul><li>Considerations </li></ul><ul><ul><li>Immediate Loading </li></ul></ul><ul><ul><ul><li>Why? </li></...
Implant Loading Immediate Loading <ul><ul><ul><li>When? </li></ul></ul></ul><ul><ul><ul><ul><li>When conditions exist that...
Delayed Loading <ul><li>Why? </li></ul><ul><ul><li>Still considered most predictable standard of care. </li></ul></ul><ul>...
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Diagnosis and treatment planning

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Diagnosis and treatment planning

  1. 1. Level II: Advanced Implant Placement and Restoration Course Dr. David Dalise Dr. Gary McCabe Ross
  2. 2. Diagnosis and Treatment Planning
  3. 3. Treatment Planning <ul><li>Patient’s desire must be determined </li></ul><ul><ul><li>Fixed or Removable </li></ul></ul><ul><li>Comprehensive Stomatognathic Assessment </li></ul>
  4. 4. Comprehensive Stomatognathic Assessment (continued) <ul><li>Health history </li></ul><ul><li>Radiographic Assessment </li></ul><ul><ul><li>Intraoral survey for dentulous patients </li></ul></ul><ul><ul><li>Extra Oral for edentulous patients </li></ul></ul><ul><ul><ul><li>Tomographic (Cone Beam) </li></ul></ul></ul><ul><ul><ul><li>Panoramic </li></ul></ul></ul>
  5. 5. Hard Tissue Evaluation <ul><li>Ridge Classifications </li></ul><ul><li>Ridge Angulation </li></ul><ul><li>Bone Density or Type </li></ul>
  6. 6. Partially Edentulous Arch with Bilateral Edentulous Areas Posterior to Remaining Natural Teeth
  7. 7. Partially Edentulous Arch with Bilateral Edentulous Areas Posterior to Remaining Natural Teeth
  8. 8. Partially Edentulous Arch with Bilateral Edentulous Areas Posterior to Remaining Natural Teeth
  9. 9. Partially Edentulous Arch with Bilateral Edentulous Areas Posterior to Remaining Natural Teeth
  10. 10. Partially Edentulous Arch with Bilateral Edentulous Areas Posterior to Remaining Natural Teeth
  11. 11. Partially Edentulous Arch with Unilateral Edentulous Area Posterior to Remaining Teeth
  12. 12. Partially Edentulous Arch with Unilateral Edentulous Area Posterior to Remaining Teeth
  13. 13. Partially Edentulous Arch with Unilateral Edentulous Area with Natural Teeth Remaining Anterior and Posterior
  14. 14. Partially Edentulous Arch with Unilateral Edentulous Area Anterior to Remaining Natural Teeth, and Crosses the Midline
  15. 15. Classification of Completely Edentulous Arches
  16. 16. Classification of Completely Edentulous Arches
  17. 17. Classification of Completely Edentulous Arches
  18. 18. Classification of Completely Edentulous Arches
  19. 19. Classification of Completely Edentulous Arches
  20. 20. Classification of Completely Edentulous Arches
  21. 21. Classification of Completely Edentulous Arches
  22. 22. Classification of Completely Edentulous Arches
  23. 23. Classification of Completely Edentulous Arches
  24. 24. Classification of Completely Edentulous Arches
  25. 25. Classification of Completely Edentulous Arches
  26. 26. Classification of Completely Edentulous Arches
  27. 27. Soft Tissue Evaluation <ul><li>Attached/Keratinized Gingival Tissue </li></ul><ul><li>Unattached/ non-Keratinized Mucosal Tissue </li></ul>
  28. 28. Occlussal Analysis <ul><li>Jaw relationship/Occlussal classification </li></ul><ul><ul><li>Class I </li></ul></ul><ul><ul><li>Class II </li></ul></ul><ul><ul><li>Class II </li></ul></ul><ul><ul><li>Crossbite </li></ul></ul><ul><ul><li>Interarch vertical dimension </li></ul></ul>
  29. 29. Occlussal Analysis <ul><li>Parafunctional analysis </li></ul><ul><ul><li>Bruxism </li></ul></ul><ul><ul><li>Clenching </li></ul></ul><ul><ul><li>Tongue Thrust </li></ul></ul><ul><ul><li>Occupational Hazards </li></ul></ul>
  30. 30. Systemic Disease <ul><li>Diabetic </li></ul><ul><li>Autoimmune diseases </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Immunosuppressed </li></ul><ul><li>Bisphosphonates </li></ul>
  31. 31. Prosthetic Analysis <ul><li>Fixed </li></ul><ul><li>Removable </li></ul><ul><ul><li>Overdenture </li></ul></ul><ul><ul><li>Hybrid </li></ul></ul>
  32. 32. Implant Placement
  33. 33. Root Form Implants <ul><li>Straight, Non-tapered body </li></ul>
  34. 34. Root Form Implants <ul><li>Tapered Body </li></ul>
  35. 35. Root Form Implants <ul><li>One-Piece Implants </li></ul>
  36. 36. Root Form Implants <ul><li>Short Implants </li></ul><ul><ul><li>< 8mm </li></ul></ul>
  37. 37. “ Mini” Implants <ul><ul><li>Less than or equal to 3.0mm </li></ul></ul>1.8mm 3.0mm I-Mini
  38. 38. Anatomical Considerations <ul><li>Mandible </li></ul><ul><ul><li>Anterior: Anterior to the mental foramen </li></ul></ul><ul><ul><ul><li>Anatomical considerations </li></ul></ul></ul><ul><ul><ul><ul><li>Angulation of alveolar process relative to occlusal/incisal plane of planned prosthetics. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Buccal/lingual width of alveolar ridge. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Vertical height of alveolar ridge. </li></ul></ul></ul></ul><ul><ul><ul><li>Bone density </li></ul></ul></ul><ul><ul><ul><ul><li>Class D1,D2, D3, or D4 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Usually type D1 or D2 </li></ul></ul></ul></ul>Note: Anterior mandible has the highest incidence of initial implant failure due to over heating of bone during osteotomy procedure. Use caution and adequate irrigation to minimize heat production during osteotomy!
  39. 39. Anatomical Considerations <ul><ul><li>Posterior: distal to the mental foramen </li></ul></ul><ul><ul><ul><li>Anatomical considerations </li></ul></ul></ul><ul><ul><ul><li>Lingual concavity </li></ul></ul></ul><ul><ul><ul><li>Location of inferior alveolar canal </li></ul></ul></ul><ul><ul><ul><li>Location of the mental foramen </li></ul></ul></ul><ul><ul><ul><li>Variation of buccal to lingual alveolar bone height </li></ul></ul></ul>Note: Bone quality in this region is usually type D2 or type D3. Rarely type D1, but possible type D4.
  40. 40. Anatomical Considerations <ul><li>Lekholm and Zarb’s four bone qualities for the anterior region of the jaws: </li></ul><ul><ul><li>Quality 1: Composed of homogenous compact bone </li></ul></ul><ul><ul><li>Quality 2: Thick layer of cortical bone surrounding dense trabecular bone. </li></ul></ul><ul><ul><li>Quality 3: Thin layer of cortical bone surrounded by dense trabecular bone of favorable strength. </li></ul></ul><ul><ul><li>Quality 4: Thin layer of cortical bone surrounding a core of low-density trabecular bone. </li></ul></ul>D1 D2 D3 D4
  41. 41. Maxilla <ul><li>Anterior (pre maxilla): anterior to the maxillary sinus </li></ul><ul><ul><li>Radiographic landmarks </li></ul></ul><ul><ul><ul><li>Anterior border of maxillary sinus </li></ul></ul></ul><ul><ul><ul><li>Nasal Antrum/Spine </li></ul></ul></ul><ul><ul><ul><li>Anterior Palatal Foramen (incisive) </li></ul></ul></ul><ul><ul><ul><li>Canine Eminence/ Fossae </li></ul></ul></ul>
  42. 42. Maxilla <ul><li>Posterior: distal to anterior border of the maxillary sinus extending to maxillary tuberosity. </li></ul><ul><ul><li>Radiographic landmarks </li></ul></ul><ul><ul><ul><li>Posterior border/ wall of the sinus </li></ul></ul></ul><ul><ul><ul><li>Medial wall of sinus </li></ul></ul></ul><ul><ul><ul><li>Floor of sinus </li></ul></ul></ul><ul><ul><ul><li>Tuberosity </li></ul></ul></ul><ul><ul><ul><li>Anomalies </li></ul></ul></ul><ul><ul><ul><ul><li>Webbing </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Mucoseals </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Polyps </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cysts </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Thickened sinus membrane </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Tumors (pathologic or benign lesions) </li></ul></ul></ul></ul>Posterior: distal to anterior border of the maxillary sinus extending to maxillary tuberosity. Note: When reading tomograph, must be able to confirm patency of maxillary sinus ostium prior to contemplating any future sinus grafts.
  43. 43. Surgical Considerations <ul><li>Access Assessment </li></ul><ul><ul><li>This is critical in determining the ability to place implants, both literally and in proper inclination for final prosthetic outcome. In basic terms, is there enough room to perform the osteotomy procedure and place the implant in an ideal/acceptable position . If not, this must be determined prior to final case design. </li></ul></ul>
  44. 44. Surgical Considerations <ul><li>Flap </li></ul><ul><ul><li>Indications/Advantages </li></ul></ul><ul><ul><ul><li>Unacceptable osseous contours requiring osteotomy or osteoplasty prior to implant placement. </li></ul></ul></ul><ul><ul><ul><li>Inadequate zone of attached/keratinized tissue in area of planned implant/abutment tissue interface. </li></ul></ul></ul><ul><ul><ul><li>Allows direct visual assessment of osseous contours in planned site for implant placement. </li></ul></ul></ul><ul><ul><ul><li>Required for two stage implant placement. </li></ul></ul></ul><ul><ul><ul><li>May be advantageous if there are concerns about bacterial contamination of implant/osseous interface. </li></ul></ul></ul><ul><ul><ul><li>Allows for primary closure over osteotomy </li></ul></ul></ul>
  45. 45. Flap (continued) <ul><ul><li>Design </li></ul></ul><ul><ul><ul><li>Considerations for proper access to osteotomy site </li></ul></ul></ul><ul><ul><ul><li>Allows for tension free flap reflection </li></ul></ul></ul><ul><ul><ul><li>Consideration for maintenance of proper gingival architecture, especially maintenance of interdental papillae. </li></ul></ul></ul><ul><ul><ul><li>Esthetic zone </li></ul></ul></ul><ul><ul><ul><li>Biotype considerations </li></ul></ul></ul><ul><ul><ul><ul><li>Thick or thin </li></ul></ul></ul></ul><ul><ul><li>Closure </li></ul></ul><ul><ul><ul><li>Primary – tension free to prevent secondary opening of suture line which is most common post operative complication. </li></ul></ul></ul><ul><ul><li>Release of Tissue </li></ul></ul><ul><ul><ul><li>Prevents tension on flap closure </li></ul></ul></ul><ul><ul><ul><li>Confirmation of adequate release should be confirmed prior to placement of grafts and/or implants, not after placement. Failure to do so may result in inability to attain primary closure over graft/implant site resulting in failure do to lack of primary closure of suture line. </li></ul></ul></ul><ul><ul><li>Anatomical considerations </li></ul></ul><ul><ul><ul><li>Neurological </li></ul></ul></ul><ul><ul><ul><li>Vascular </li></ul></ul></ul><ul><ul><ul><li>Boney (Osseous) </li></ul></ul></ul>
  46. 46. Flap, Anatomical Considerations (continued) <ul><ul><ul><li>Neurological – Be aware of location of nerve bundles prior to incisions for flap release. </li></ul></ul></ul><ul><ul><ul><ul><li>i.e.: Location of the mental foramen, incisive foramen, infraorbital foramen, lingual branch inferior alveolar nerve, and posterior palatal nerve. </li></ul></ul></ul></ul><ul><ul><ul><li>Vascular </li></ul></ul></ul><ul><ul><ul><ul><li>Must know location of vascular bundles prior to initiation of incision for flap. i.e.: Facial artery, lingual artery, incisive canal, mental artery, palatal artery. </li></ul></ul></ul></ul><ul><ul><ul><li>Boney (Osseous) </li></ul></ul></ul><ul><ul><ul><ul><li>Location of prominent boney eminences and relationship to proper flap design. i.e.: Canine eminence, anterior nasal spine, maxillary tuberosity, retro molar pad. </li></ul></ul></ul></ul><ul><ul><ul><li>Muscular </li></ul></ul></ul><ul><ul><ul><ul><li>Frenum attachments </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Massetter muscle </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pterygoid muscles </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Labialis muscles/obiquilaris-oris </li></ul></ul></ul></ul><ul><ul><ul><li>Glandular </li></ul></ul></ul><ul><ul><ul><ul><li>Need to pay attention to the sublingual salivary glands. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Need to pay attention to the salivary ducts. </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Sublingual </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Parotid gland/duct </li></ul></ul></ul></ul></ul>
  47. 47. Single Tooth Esthetic Zone (preop) Incisal View
  48. 48. Single Tooth Esthetic Zone (preop) Labial View
  49. 49. Papillae Saving Incision
  50. 50. Extension to Lingual
  51. 51. Tissue Flap Release
  52. 52. Flap Release Continued
  53. 53. Initiation of Osteotomy Utilizing Osteotomes
  54. 54. Implant Placed with Cover Screw
  55. 55. Primary Closure
  56. 56. Flapless Surgery <ul><ul><li>Indications/Advantages </li></ul></ul><ul><ul><ul><li>Well documented, adequate bone height and width. </li></ul></ul></ul><ul><ul><ul><li>Adequate zone of attached keratinized tissue. </li></ul></ul></ul><ul><ul><ul><li>Reduced surgical time </li></ul></ul></ul><ul><ul><ul><li>Reduced post operative healing sequelae </li></ul></ul></ul><ul><ul><ul><li>Less perceived trauma by the patient. </li></ul></ul></ul><ul><ul><ul><li>Increases patient acceptance of procedures. </li></ul></ul></ul><ul><ul><li>Determining location of osteotomy </li></ul></ul><ul><ul><ul><li>Site should be predetermined with diagnostic wax up and/or surgical stent. </li></ul></ul></ul><ul><ul><ul><li>Occlusal loading and force vectors ultimately determine location of implant osteotomy. </li></ul></ul></ul><ul><ul><ul><li>Root angulation and proximity of existing teeth must be considered. </li></ul></ul></ul><ul><ul><ul><li>Anterior or Posterior esthetic or non esthetic zone. </li></ul></ul></ul><ul><ul><ul><ul><li>Biotype of tissue </li></ul></ul></ul></ul>
  57. 57. Flapless Surgery <ul><ul><li>Methodology </li></ul></ul><ul><ul><ul><li>Anesthetize patient appropriately for procedure </li></ul></ul></ul><ul><ul><ul><ul><li>Infiltration or Nerve Block as indicated </li></ul></ul></ul></ul><ul><ul><ul><li>Place surgical guide </li></ul></ul></ul><ul><ul><ul><ul><li>This should be stabilized either by existing dentition or on non-mobile anatomical bone supported tissues </li></ul></ul></ul></ul><ul><ul><ul><li>Mark the tissue with either dye or surgical probe to produce bleeding point or with pilot drill. </li></ul></ul></ul><ul><ul><ul><li>Pilot hole/Tissue Punch/Guide Pin </li></ul></ul></ul><ul><ul><ul><ul><li>Sequence can vary according to circumstance </li></ul></ul></ul></ul><ul><ul><ul><li>Initial osteotomy/pilot hole </li></ul></ul></ul><ul><ul><ul><li>Check alignment/insertion angle with guide pin </li></ul></ul></ul><ul><ul><ul><ul><li>Visual </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Radiographic </li></ul></ul></ul></ul><ul><ul><ul><li>Finish osteotomy </li></ul></ul></ul><ul><ul><ul><li>Implant Placement </li></ul></ul></ul><ul><ul><ul><ul><li>Torque to appropriate levels </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Maxillary – 20 N/Cm minimum </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Mandibular – 30 N/Cm minimum </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Temporize as indicated </li></ul></ul></ul><ul><ul><li>Armementarium </li></ul></ul>
  58. 58. Flapless Surgery <ul><ul><li>Armamentarium </li></ul></ul><ul><ul><ul><li>Surgical Stent </li></ul></ul></ul><ul><ul><ul><li>Implant Surgical Kit </li></ul></ul></ul><ul><ul><ul><li>Appropriate Tissue Marking Implements </li></ul></ul></ul><ul><ul><ul><ul><li>I.E. Denture marking stick, probe, or tissue punch </li></ul></ul></ul></ul><ul><ul><ul><li>Tissue Punch </li></ul></ul></ul><ul><ul><ul><ul><li>Rotary </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Disposable </li></ul></ul></ul></ul><ul><ul><ul><li>High speed handpiece with irrigation </li></ul></ul></ul><ul><ul><ul><li>#8 Round Bur </li></ul></ul></ul>
  59. 59. Case Example # 2 Pre Operative
  60. 60. Pre Operative Ridge
  61. 61. Pre Operative Ridge Occlusal View
  62. 62. Acrylic Stent in Place
  63. 63. Marking Ridge Utilizing Acrylic Stent
  64. 64. Marking Ridge Utilizing Acrylic Stent
  65. 65. Osteotomy Sites Marked On Ridge
  66. 66. Tissue Punch Pre Osteotomy
  67. 67. Appearance of Ridge Following Initial Use of Tissue Punch
  68. 68. Removal of Tissue Plug and Initiation of Pilot Hole (#8 Bur)
  69. 69. Appearance of Ridge Following Removal of Tissue Plug
  70. 70. Appearance of Ridge Following Removal of Tissue Plug
  71. 71. Pilot Drill – Initial Osteotomy
  72. 72. Flapped to Expose Bone Fixation Screws for Removal Prior to Implant Placement
  73. 73. Bone Fixation Screw
  74. 74. Occlusal View
  75. 75. Removal of Fixation Screw
  76. 76. Ligated Paralleling Pin
  77. 77. Ligated Paralleling Pins
  78. 78. Implant Placement with Handpiece
  79. 79. Implant Placement with Handpiece
  80. 80. Implant Placement with Handpiece
  81. 81. Implant Placement with Handpiece
  82. 82. Implant Placement with Handpiece Implant Seated to Proper Depth
  83. 83. Implant Placement with Handpiece Implant Seated to Proper Depth
  84. 84. Implant Placement Prior to Soft Tissue Closure
  85. 85. Placement of Healing Abutments/Temporary Abutments
  86. 86. Occlusal View
  87. 87. Flap Closure
  88. 88. Flap Closure
  89. 89. Flap Closure
  90. 90. Final Occlusal View
  91. 91. Temporary Abutments Prepared for Use with Temporaries
  92. 92. Temporary Stent in Place Over Implants
  93. 93. Finalizing Reduction of Temporary Abutments
  94. 94. Obturation of Abutment Access
  95. 95. Use of Tempit Light Cure to Close Access Hole
  96. 96. Prefabricated Silicone Temporary Stent
  97. 97. Temporary Stent with BIS-Acrylic Temporary Material in Place
  98. 98. Immediate Post Operative Temporization
  99. 99. Osteotomies <ul><li>Mark intended location of entry point </li></ul><ul><li>Pilot hole </li></ul><ul><li>Alignment verification </li></ul><ul><li>Tissue Punch if flapless </li></ul><ul><li>Completion </li></ul><ul><ul><li>Rotary (excavation) </li></ul></ul><ul><ul><ul><li>Use of rotary osteotomy drills </li></ul></ul></ul><ul><ul><li>Osteotomes (condensation) </li></ul></ul><ul><ul><ul><li>Expansion of bone </li></ul></ul></ul><ul><ul><ul><li>Slow sequential increase in size of osteotome </li></ul></ul></ul><ul><ul><ul><li>Final size of osteotome determined by bone type/density </li></ul></ul></ul><ul><ul><ul><ul><li>I.E. D1, D2, D3, and D4 </li></ul></ul></ul></ul>
  100. 100. Implant Placement <ul><li>Delivery to osteotomy </li></ul><ul><ul><li>Hand Placement </li></ul></ul><ul><ul><li>Rotary Handpiece Placement </li></ul></ul><ul><li>Seating to final depth </li></ul><ul><ul><li>Assure alignment buccal lingually if implant is contoured </li></ul></ul><ul><ul><li>Verify proper depth of implant/abutment platform relative to proper tissue emergence profile </li></ul></ul><ul><li>Verification of proper placement </li></ul><ul><ul><li>Clinical appearance </li></ul></ul><ul><ul><li>Radiographic </li></ul></ul>
  101. 101. Implant Placement <ul><li>Revisions </li></ul><ul><ul><li>Realignment of osteotomy </li></ul></ul><ul><ul><ul><li>Correct as early as possible. Pilot hole and alignment check should be first indication that osteotomy needs correction. </li></ul></ul></ul><ul><ul><li>Removal of implant </li></ul></ul><ul><ul><ul><li>Remove implant immediately if there are indications that implant may cause problems with existing teeth or neurologic/vascular bundles. </li></ul></ul></ul><ul><ul><li>Salvaging a problematic implant placement </li></ul></ul><ul><ul><ul><li>Oversize implants </li></ul></ul></ul><ul><ul><ul><ul><li>Reserved only to salvage inadvertent oversized osteotomy </li></ul></ul></ul></ul><ul><ul><ul><li>Revising the depth of the osteotomy </li></ul></ul></ul><ul><ul><ul><ul><li>Remove implant </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Revise osteotomy to proper depth </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Replace implant </li></ul></ul></ul></ul>
  102. 102. Immediate Post Placement Options <ul><li>Two-stage option </li></ul><ul><ul><li>Place cover screw and close it; flap was utilized </li></ul></ul><ul><ul><li>Flapless option. Place cover screw and allow to close by secondary intention. </li></ul></ul><ul><ul><ul><li>This option would be used if conditions allow for flapless surgery; however, no inadvertent loading of implants is desired. </li></ul></ul></ul>
  103. 103. Immediate Post Placement Options <ul><li>One stage option </li></ul><ul><ul><li>Place healing abutment </li></ul></ul><ul><ul><ul><li>Select proper height </li></ul></ul></ul><ul><ul><ul><ul><li>Healing abutment should protrude at least to the level of tissue </li></ul></ul></ul></ul><ul><ul><ul><li>Adaptation to prosthetics </li></ul></ul></ul><ul><ul><ul><ul><li>Modification of Healing Abutments or Temporary Abutments to allow for placement of temporaries. </li></ul></ul></ul></ul><ul><ul><li>Place Restorative Abutment </li></ul></ul><ul><ul><ul><li>Select proper abutment type </li></ul></ul></ul><ul><ul><ul><ul><li>Cementable prosthesis </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Generally most preferable and least problematic for crown and bridge applications </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Screw retained prosthesis </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>For use in situations with limited or inadequate abutment height for adequate retention of prosthesis or for splinted bar type overdenture prosthetics. </li></ul></ul></ul></ul></ul>
  104. 104. One Piece Implants <ul><li>Why? </li></ul><ul><ul><li>Strongest </li></ul></ul><ul><ul><li>Eliminate abutment/implant interface </li></ul></ul><ul><ul><ul><li>Initial bone loss/saucerization </li></ul></ul></ul><ul><ul><li>Simplify temporization </li></ul></ul><ul><ul><li>Simplify prosthetic procedures </li></ul></ul><ul><ul><li>Lowest cost </li></ul></ul><ul><li>When? </li></ul><ul><ul><li>Ability to place implant in the ideal circumstances </li></ul></ul><ul><ul><ul><li>Ideal inclination of implant and abutment relative to existing dentition or planned prosthetic design. </li></ul></ul></ul><ul><ul><li>No contraindicated pre existing parafunction </li></ul></ul><ul><ul><ul><li>Bruxism </li></ul></ul></ul><ul><ul><ul><li>Tongue thrust </li></ul></ul></ul><ul><ul><ul><li>Cross bite </li></ul></ul></ul><ul><ul><ul><li>Unusual lateral forces on implant/abutment </li></ul></ul></ul><ul><li>Where </li></ul><ul><ul><li>Anterior or posterior when appropriate </li></ul></ul><ul><ul><li>Highly dependent on desired anticipated outcomes </li></ul></ul>
  105. 105. One Piece Implants <ul><li>Temporization options </li></ul><ul><ul><li>Adaptation to pre existing prosthetics </li></ul></ul><ul><ul><ul><li>Implant must be determined to be stable enough to accept immediate load if this option is selected. </li></ul></ul></ul><ul><ul><li>Fabrication of new temporaries </li></ul></ul><ul><ul><ul><li>Prefabricated </li></ul></ul></ul><ul><ul><ul><ul><li>ION type crown forms modified with appropriate liner to adapt to margin of implant/abutment. </li></ul></ul></ul></ul><ul><ul><ul><li>Immediate, in the mouth fabrication </li></ul></ul></ul><ul><ul><ul><ul><li>Pre made silicone mold fabricated from diagnostic wax up. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Use of pre extraction/implant site impression (elastomeric type) </li></ul></ul></ul></ul>
  106. 106. Implant Loading <ul><li>Considerations </li></ul><ul><ul><li>Immediate Loading </li></ul></ul><ul><ul><ul><li>Why? </li></ul></ul></ul><ul><ul><ul><ul><li>Improves patient acceptance/satisfaction with implant procedures due to immediate gratification and perceivable results. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>May improve hard and soft tissue responses and esthetics in critical zones. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Can usually justify a higher fee in accordance with acceptance of higher risk of failure by both practitioner and patient. </li></ul></ul></ul></ul>
  107. 107. Implant Loading Immediate Loading <ul><ul><ul><li>When? </li></ul></ul></ul><ul><ul><ul><ul><li>When conditions exist that allow for idealized immediate stabilization of implant with minimal contraindications predisposing the implant to failure. </li></ul></ul></ul></ul><ul><ul><ul><li>How? </li></ul></ul></ul><ul><ul><ul><ul><li>Implant must be stabilize with an immediate loading torque of not less than 40 N/Cm and ideally up to 55 N/Cm. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Temporary must be placed with no lateral occlusal/parafunctional forces. </li></ul></ul></ul></ul>
  108. 108. Delayed Loading <ul><li>Why? </li></ul><ul><ul><li>Still considered most predictable standard of care. </li></ul></ul><ul><ul><li>Minimizes or eliminates detrimental functional stresses on implants during integration phase. </li></ul></ul><ul><ul><li>No immediate availability of temporary or final prosthetic solution. </li></ul></ul><ul><li>Where? </li></ul><ul><ul><li>Any place that is contraindicated for immediate loading. </li></ul></ul>
  109. 109. THANK YOU Questions?
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