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  • 1. Dental implants Islam Kassem Level 9 ikassem@dr.com
  • 2. WHAT IS A DENTAL IMPLANT?  Dental implant is an artificial titanium fixture which is placed surgically into the jaw bone to substitute for a missing tooth and its root(s).
  • 3. History of Dental Implants In 1952, Professor Per-Ingvar Branemark, a Swedish surgeon, while conducting researchinto the healing patterns of bone tissue, accidentally discovered that when pure titanium comes into direct contact with the living bone tissue, the two literally grow together to form a permanent biological adhesion. He named this phenomenon "osseointegration".
  • 4. First Implant Design by Branemark All current implant designs are modifications of this initial design
  • 5. Surgical Procedure STEP 1: INITIAL SURGERY STEP 2: OSSEOINTEGRATION PERIOD STEP 3: ABUTMENT CONNECTION STEP 4: FINAL PROSTHETIC RESTORATION
  • 6. Fibro-osseous integration• Fibroosseous integration– “tissue to implant contact with dense collagenoustissue between the implant and bone”• Seen in earlier implant systems.• Initially good success rates but extremelypoor long term success.• Considered a “failure” by todays standards
  • 7. Microscopic
  • 8. Osseointegration• Success Rates >90%• Histologic definition – “direct connection between living bone and load- bearing endosseous implants at the light microscopic level.”• 4 factors that influence: Biocompatible material Implant adapted to prepared site Atraumatic surgery Undisturbed healing phase
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  • 40. Soft-tissue to implant interface• Successful implants have an – Unbroken, perimucosal seal between the soft tissue and the implant abutment surface.• Connect similarly to natural teeth-some differences. – Epithelium attaches to surface of titanium much like a natural tooth through a basal lamina and the formation of hemidesmosomes.
  • 41. Soft-tissue to implant interface• Connection differs at the connective tissue level. • Natural tooth Sharpies fibers extent from the bundle bone of the lamina dura and insert into the cementum of the tooth root surface • Implant: No Cementum or Fiber insertion. Hence the Epithelial surface attachment is IMPORTANT
  • 42. Endosteal Implants
  • 43. The “Parts”• Implant body-fixture• Abutment (gingival/temporary healing vs. final)• Prosthetics
  • 44. Clinical Components
  • 45. abutment
  • 46. Surgical Phase- Treatment Planning• Evaluation of Implant Site• Radiographic Evaluation• Bone Height, Bone Width and Anatomic considerations
  • 47. Basic Principles• Soft/ hard tissue graft bed• Existing occlusion/ dentition• Simultaneous vs. delayed reconstruction
  • 48. Anatomic Considerations• Ridge relationship• Attached tissue• Interarch clearance• Inferior alveolar nerve• Maxillary sinus• Floor of nose
  • 49. Limitations to Implant placement in the Maxilla • Ridge width • Ridge height • Bone quality
  • 50. Anatomic LimitationsBuccal Plate 0.5mmLingual Plate 1.0 mmMaxillary Sinus 1.0 mmNasal Cavity 1.0mmIncisive canal AvoidInterimplant distance 1-1.5mmInferior alveolar canal 2.0mmMental nerve 5mm from foramenInferior border 1 mmAdjacent to natural tooth 0.5mm
  • 51. Placement ofhealing abutment
  • 52. Planning of dental implants ikassem@dr.com
  • 53. Patient Evaluation• Medical history – vascular disease – immunodeficiency – diabetes mellitus – tobacco use – bisphosphonate use ikassem@dr.com
  • 54. History of Implant Site• Factors regarding loss of tooth being replaced – When? – How? – Why?• Factors that may affect hard and soft tissues: – Traumatic injuries – Failed endodontic procedures – Periodontal disease• Clinical exam may identify ridge deficiencies ikassem@dr.com
  • 55. Functional examinationExamination of smile:  Ackerman et al differentiated between two types of smile: - posed smile (social smile, forced smile) … voluntary, reproducible. - spontaneous smile ( enjoyment smile) … involuntary, induced by joy. ikassem@dr.com
  • 56. Examination of smile Ackerman et al used a “smile mesh” computer program to analyze photographs of posed smiles using the Occlusal Plane and the Dental Midline as reference planes. He concluded that the posed smile is reproducible if photographs were taken On The Same Day ikassem@dr.com
  • 57.  Smile related to natural dentition: (SMILE LINE) - posed smile … the smile-line is at the gingival margin. - lower smile-line … senile appearance. ikassem@dr.com
  • 58. Smile Line• One of the most influencing factors of any prosthodontic restoration• If no gingival shows then the soft tissue quality, quantity and contours are less important• Patient counseling on treatment expectations is critical ikassem@dr.com
  • 59. SMILE LINE FEMALE MALE MORE GINGIVAL DISPLAY LESS GINGIVAL DISPLAY MORE LOWER INCISOR SHOW ikassem@dr.com
  • 60. SMILE ARC: - Consonant  the curvature of the max. incisors is parallel to that of the lower lip. - nonconsonant  the curvature of the max. incisors is flat … senile appearance. ikassem@dr.com
  • 61. SMILE ARC: NORMAL REVERSE (CONSONANT) ikassem@dr.com
  • 62. Transverse dimension of smile: - broad smile … 1st molar may be shown at the commissures. - buccal corridors … improved by : 1- maxillary widening. 2- ,, advancement. ikassem@dr.com
  • 63. BUCCAL CORRIDORS:(NEGATIVE SPACE) ikassem@dr.com
  • 64. Alternative SolutionsPartial and Full DenturesCrownsBridges ikassem@dr.com
  • 65. Biocompatibility of MaterialDesired Mechanical Surfaces Properties • Composition• High yield strength • Ion release• Modulus close to that of bone’s • Surface• Built-in margin of modifications safety: Changes in environment around implant ikassem@dr.com
  • 66. Metallic Implant SurfaceProblem: Implant surface change with time due to oxidation, precipitation…Possible solutions:• Oxide layers ( minimize ion release)• Prosthetic component from noble alloys• Phase stabilizers other than Al & V (eg. Ti-13Nb- 13Zr, Ti-15Mo-2.8Nb )• Surface Modifications ikassem@dr.com
  • 67. Types of Implants Screw Implants (Left to Right: TPS screw, Ledermann screw, Branemark screw, ITI Bonefit screw) Cylinder Implants (Left to Right: IMZ, Integral, Frialit-1 step-cylinder, Frialit-2 step-cylinder) ikassem@dr.com
  • 68. ProcedureFirst Surgical Phase (Implant Placement)Under Local anesthetic the dentist places dentalimplants into the jaw bone with a very precisesurgical procedure. The implant remains coveredby gum tissue while fusing to the jaw bone.Second Surgical Phase (Implant Uncovery)After approximately six months of healing. Underlocal anesthetic, the implant root is exposed and ahealing post is placed over top of it so that thegum tissue heals around the post.Prosthetic Phase (Teeth)Once the gums have healed, an implant crown isfabricated and screwed down to the implant. ikassem@dr.com
  • 69. What Is A Dental Implant?Dental implants are used to: Replace a missing tooth Replace multiple missing teeth Replace an edentulous arch ikassem@dr.com
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  • 71. Implant vs Conventional Bridges vs. Removable Dentures • There is a clear benefit to receiving dental implants • Quality of life improves • Diet and nutrition are positively impacted • Positive impact on leisure activities • Disadvantage of cutting down perfectly healthy teeth ikassem@dr.com
  • 72. Patient Friendly ProceduresPatients want: Fast procedures Minimally invasive procedures Long lasting results Good esthetics ikassem@dr.com
  • 73. Doctor Friendly Procedures• Transition from 2-stage to 1-stage procedures• Immediate load implants• Less invasive dental implant therapy• Tilted implants, guided flapless surgery• Advances in ceramic materials create a shift from function to esthetics ikassem@dr.com
  • 74. Concerns About RecommendingDental Implants for the Elderly Fact or Fiction… Longer healing time Inadequate osseointegration of implants Loss of implants due to inadequate oral hygiene Patient’s desire and expectations for dental implants may differ with age ikassem@dr.com
  • 75. Patient’s Expectations• Increased resistance to implant surgery - “I’m too old”.• Long-term edentulous patients may be more tolerant to ill-fitting conventional dentures.• Recommendations for implant-assisted restorations should occur early in edentulism.• Elderly patients may take a greater period of time to adapt to a new prosthesis. ikassem@dr.com
  • 76. Success Rate of Implant Placement• Success rate of implants in the healthy elderly population is the same as that of younger age groups.• Degree of osseointegration with healthy geriatric patients is comparable to that of the younger population. ikassem@dr.com
  • 77. Mandibular Overdentures• Improve the stability and retention of the denture.• Can be placed over tooth roots or over implants.• Tooth roots provide sensory feedback but can decay or lose support due to periodontal disease or fracture.• Both tooth roots or implants will help retain the bone in the mandibular ridge. ikassem@dr.com
  • 78. Growing Need for Satisfactory Tooth Replacement• Tooth replacement with implant-supported or assisted dentures provides greater patient satisfaction with comfort and chewing.• Stability and retention of denture is improved. ikassem@dr.com
  • 79. Risk Factors for Dental Implant Success in the Elderly• Oral Hygiene• Xerostomia• Cardiovascular disease• Diabetes• Osteoporosis• Cancer Implant therapy should be considered as a medical model in the geriatric population. ikassem@dr.com
  • 80. Lessened Manual Dexterity and Visual Acuity May Affect Oral Self Care Oral HygieneSuccess rate may be comparable to younger agegroups when…• Appropriate modifications of oral health aids are made.• When adequate instruction and recall intervals are maintained.• Less complicated designs of implant abutments are utilized. ikassem@dr.com
  • 81. SURGICAL REQUIREMENTSStandardised surgical protocolSurgical environmentImplant equipment - reusable -disposable/single useFully evaluated and prepared patientTrained staff ikassem@dr.com
  • 82. EQUIPMENT FIRST STAGE ikassem@dr.com
  • 83. STAINLESS STEEL• Guide drill• 2mm twist drill• Pilot drill• 3mm twist drill• Countersink ikassem@dr.com
  • 84. TITANIUM• Tap• Implant• Coverscrew ikassem@dr.com
  • 85. ANAESTHESIA• General• Local• Sedation ikassem@dr.com
  • 86. SURGICAL• Aseptic technique• Gentleness• Precision ikassem@dr.com
  • 87. SURGICAL PRELIMINARIES• Induction of anaesthesia• Endotracheal intubation• Throat pack• Scrub and gown• Surgical preparation• Draping ikassem@dr.com
  • 88. SURGICAL PROCEDURE • Local Anaesthetic • Try in stent • Tattoo • Surgical incision • Flap reflection • Flap retraction • Try in stent ikassem@dr.com
  • 89. SURGICAL PROCEDURE • Smooth ridge • Use stent • Guide drill • Small twist drill • Pilot drill • Large twist drill • Depth guide ikassem@dr.com
  • 90. SURGICAL PROCEDURE • Countersink • Fixture insertion • Cover screw • Debridement • Closure ikassem@dr.com
  • 91. POSTOPERATIVE CARE• Haemostasis• Analgesia• Antibiotic regime• Chlorhexidine mouthwash• Suture removal• Temporary prosthesis ikassem@dr.com
  • 92. SECOND STAGE• Soft tissue• Bone removal• Cover screw removal• Healing abutment• Replacement• Dressings ikassem@dr.com
  • 93. KEY POINTS• Implant positioning - bucco/lingual - axial - separation• Drill speeds - 2000rpm - 20rpm• Torque• Irrigation ikassem@dr.com
  • 94. MAXILLARY IMPLANTS• Lack of well defined cortex• Poorer quality cancellous bone• Lack of bucco/lingual width• Reduced height of available bone• Proximity of anatomical structures- nose - antrum - incisive canal ikassem@dr.com
  • 95. COMPLICATIONS WITHOSSEOINTEGRATED IMPLANTS ikassem@dr.com
  • 96. COMPLICATIONS• Preoperative• Perioperative• Postoperative• Transient• Persistent• Permanent• Soft tissue• Hard tissue ikassem@dr.com
  • 97. SERIOUS COMPLICATIONS– Jaw fracture– Haemorrhage– Ingestion– Inhalation– Neurological– Death ikassem@dr.com
  • 98. COMPLICATIONS• Patient selection – Psyche – Anatomy – Systemic disease• Implant factors• Surgical• Prosthodontic• Errors in judgement• Deviation from established protocol ikassem@dr.com
  • 99. ANATOMY• Unsuitable morphologically• Reduced bone density• Reduced bone volume• Attached tissue• Nerve position ikassem@dr.com
  • 100. PREVENTION OF NERVE DAMAGE• CT• Bone density measurement• Drill sleeves• Discretion is better part of valour ikassem@dr.com
  • 101. COMPLICATIONSPeroperative – Failure to obtain anaesthesia – Haemorrhage – Stuck implant – Loose implant – Lost implant ikassem@dr.com
  • 102. SURGICAL FAILURE• Poor planning• Poor surgical technique• Lack of precision• Thermal injury• Faulty placement• Damage to adjacent structures ikassem@dr.com
  • 103. SURGICAL• Haemorrhage• Stuck implant• Loose implant• Lost implant ikassem@dr.com
  • 104. COMPLICATIONS• Wound dehiscence• Infection• Mucosal perforation• Fistula formation• Anatomical - antral - nasal - neurological ikassem@dr.com
  • 105. STAGE ONE SURGERY• Failure to obtain anaesthesia• Faulty placement• Anatomical• Surgical ikassem@dr.com
  • 106. SURGICAL• Stripped bone threads• Exposed implant threads• Fractured drill• Sheared implant hex• Excessive countersink• Eccentric drill ikassem@dr.com
  • 107. COMPLICATIONSSecond stage – Loose implant – Excess bone coverage – Exposed threads – Coverscrew problems ikassem@dr.com
  • 108. STAGE TWO SURGERY• Wrong abutment length• Faulty abutment seating• Retained sutures• Gingival hyperplasia• Mobile tissue• Destroyed cover screw hex• Failure of integration ikassem@dr.com
  • 109. FAULTY PLACEMENT• Labial / buccal• Lingual• Too close• Straight line in mandibular anteriors• Angulation• Divergence• Correct by use of a surgical template ikassem@dr.com
  • 110. POSTOPERATIVE• Fascial space infections• Haematoma• Jaw fracture• Sinusitis• Wound dehiscence ikassem@dr.com
  • 111. WOUND DEHISCENCE• Poor flap design• Poor surgical technique• Poor repair• Poor tissue quality• Previous surgery• Underlying medical condition• Superficial implant placement ikassem@dr.com
  • 112. PERSISTENT• Neurological damage• Aesthetics• Speech• Function• Psychological ikassem@dr.com
  • 113. PROSTHODONTIC• Avoid premature loading• Passive fit• Good design• Good oral hygiene• Loss of integration• Soft tissue problems• Oral hygiene and maintenance• Retrievable v cemented ikassem@dr.com
  • 114. COMPONENT FAILURE• Fractured fixture• Fractured abutment screw• Fractured punch blade• Fractured screw driver tip• Fractured castings ikassem@dr.com
  • 115. MANAGEMENT OF FAILURE• Failing implants FAIL• Removal• Abandon• Alternative site• Larger diameter• Replacement after healing ikassem@dr.com
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  • 120. Bone graft for implant dentistry ikassem@dr.com
  • 121. Diagnosis and Treatment Planning For Bone Augmentation Radiographic Examination • Panoramic radiograph • 20 to 30% distortion/magnification of the anatomic structures • Buccal to lingual width will not be appreciated • Alveolar bone height, adjacent teeth and anatomic structure
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  • 126. Factors that impact on fit: atrophy1. Atrophy a. Decreasing bone b. Increasing soft tissue1 3 2 4
  • 127. Factors that impact on fit: atrophy1. Atrophy a. Decreasing bone b. Increasing soft tissue
  • 128. Factors that impact on fit: atrophy1. Atrophy a. Decreasing bone b. Increasing soft tissue
  • 129. Diagnosis and Treatment Planning For Bone Augmentation Clinical Examination • Minimal obtain 1 to 2mm of attached gingiva • Cross section of the alveolar depicting periodontal probe placement for “sounding the bone”. • To determine bone width • Cutting the study model in the exact vertical location
  • 130. To Determine Bone WidthHarry Dym, Orrett E. Ogle: Atlas of Minor Oral Surgery. W.B. Saunderscompany. 2001
  • 131. ikassem@dr.com
  • 132. GRAFTING TECHNIQUES ikassem@dr.com
  • 133. GRAFTINGAutogenous - Local symphysis third molar angle tuberosity - Distant rib iliac crest tibia calvarialAllogenic - frozen - freeze dried - demineralized ikassem@dr.com
  • 134. BIOMATERIALS- methyl methacrylate- silicone- proplast- teflon- calcium phosphates - plaster of paris - tricalcium phosphate - hydroxyapatite - goretex ikassem@dr.com
  • 135. GRAFTS• Autogenous bone• Freeze dried bone• Synthetic biomaterials ikassem@dr.com
  • 136. FREEZE DRIED BONE• Commercial preparation• Multiple donors• Screened for HIV, Hep B and C• Sterilised by irradiation• Risk of prion borne disease ikassem@dr.com
  • 137. CALCIUM PHOSPHATES• Plaster of paris• Tricalcium phosphate• Hydroxyapatite ikassem@dr.com
  • 138. INDICATIONS FOR GRAFTING• Anterior maxilla• Posterior maxilla• Anterior mandible• Posterior mandible• After resection• Post traumatic ikassem@dr.com
  • 139. TECHNIQUES• Cortico-cancellous blocks• Trephined core• Sinus Lift• Vascularised bone flap ikassem@dr.com
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  • 141. Sinus floor elevation technique1- Internal2-External ikassem@dr.com
  • 142. Surgical Solutions to Anatomical LimitationsOnlay Bone Graft Sinus Lift ikassem@dr.com
  • 143. Radiological/Imaging Studies• Periapical radiographs• Panoramic radiograph• Site specific tomograms• CAT scan (Denta-scan, cone beam CT) ikassem@dr.com
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  • 145. Anatomic LimitationsBuccal Plate 0.5mmLingual Plate 1.0 mmMaxillary Sinus 1.0 mmNasal Cavity 1.0mmIncisive canal AvoidInterimplant distance 1-1.5mmInferior alveolar canal 2.0mmMental nerve 5mm from foramenInferior border 1 mmAdjacent to natural tooth 0.5mm ikassem@dr.com
  • 146. Types of Bone Grafts• Autograft – A graft taken from on anatomic location and placed in another location in the same individual(e.g., iliac crest)• Allograft – A graft taken from a cadever treated wit certain sterilization and antiantigenic procedures and placed into a living host• Alloplast – A chemically derived nonanimal material• Xenograft – A graft taken from a nonhuman host for implantation into a human host
  • 147. Biology of Bone Grafts• Phase I – Osteogenesis: Immediate proliferation of transplanted osteocytes and subsequent formation of osteoid(immature bone)• Phase II – Osteoinduction: inducement of mesenchymal cells to produce bone(BMP) – Osteoconduction: framework or scaffold for the formation of new bone tissue
  • 148. Autogenous Bone Graft• “Gold standard” – Standard by which other materials are judged• May provide osteoconduction, osteoinduction and osteogenesis• Drawbacks – Limited supply – Donor site morbidity
  • 149. Autogenous Bone Grafts• Cancellous• Cortical• Free vascular transfers• Bone marrow aspirate
  • 150. Cancellous Bone Grafts• Three dimensional scaffold (osteoconductive)• Osteocytes and stem cells (osteogenic)• A small quantity of growth factors (osteoinductive)• Little initial structural support• Can gain support quickly as bone is formed
  • 151. Cortical Bone Grafts• Less biologically active than cancellous bone – Less porous, less surface area, less cellular matrix – Prologed time to revascularizarion• Provides more structural support – Can be used to span defects• Vascularized cortical grafts – Better structural support due to earlier incorporation – Also osteogenic, osteoinductive • Transported periosteum
  • 152. Bone Marrow Aspirate• Osteogenic – Mesenchymal stem cells (osteoprogenitor cells) exist in a 1:50,000 ratio to nucleated cells in marrow aspirate – Numbers decrease with advancing age – Can be used in combination with an osteoconductive matrix
  • 153. Autograft Harvest• Cancellous – Iliac crest (most common) • Anterior- taken from gluteus medius pillar • Posterior- taken from posterior ilium near SI joint – Metaphyseal bone • May offer local source for graft harvest – Greater trochanter, distal femur, proximal or distal tibia, calcaneus, olecranon, distal radius, proximal humerus
  • 154. Autograft Harvest• Cancellous harvest technique – Cortical window made with osteotomes • Cancellous bone harvested with gouge or currette – Can be done with trephine instrument • Circular drills for dowel harvest • Commercially available trephines or “harvesters” • Can be a percutaneus procedure
  • 155. Autograft Harvest• Cortical – Fibula common donor • Avoid distal fibula to protect ankle function • Preserve head to keep LCL, hamstrings intact – Iliac crest • Cortical or tricortical pieces can be harvested in shape to fill defect
  • 156. Bone Allografts• Cancellous or cortical – Plentiful supply – Limited infection risk (varies based on processing method) – Provide osteoconductive scaffold – May provide structural support
  • 157. Bone Allografts• Available in various forms – Processing methods may vary between companies / agencies• Fresh• Fresh Frozen• Freeze Dried
  • 158. Bone Allografts• Fresh – Highly antigenic – Limited time to test for immunogenicityor diseases – Use limited to joint replacement using shape matched osteochondral allografts
  • 159. Bone Allografts• Fresh frozen – Less antigenic – Time to test for diseases – Strictly regulated by FDA – Preserves biomechanical properties • Good for structural grafts
  • 160. Bone Allografts• Freeze-dried – Even less antigenic – Time to test for diseases – Strictly regulated by FDA – Can be stored at room temperature up – to 5 years – Mechanical properties degrade
  • 161. Bone Graft Substitutes• Mechanical properties vary widely – Dependant on composition • Calcium phosphate cement has highest compressive strength • Cancellous bone compressive strength is relatively low • Many substitutes have compressive strengths similar to cancellous bone • All designed to be used with internal fixation
  • 162. Grafting of the Extraction Socket• The teeth are extracted atraumatically preserving the buccal bone.• All granulation tissue is excised with the use of a surgical curette or a Rongeur.
  • 163. Bone Morphogenetic Proteins• Produced by recombinant technology• Two most extensively studied and commercially available – BMP-2 (Infuse) Medtronics – BMP-7 (OP-1) Stryker Biotech
  • 164. Harvesting Techniques III Cortical Onlay Bone Graft • Inadequate buccal to lingual/palatal width • Autogenous bone: donor sites-mandibular symphysis, mandibular ramus, calvarium or iliac crest • Allografts: demineralized freeze dried bone allograft blocks, freeze-dried blocks, and/or particles
  • 165. Interpositional Ridge Graft• The approximate depth of the osteotomy should be 1cm.• A bibevel chisel is used to gently outfracture the buccal plate and allow enough width for the proposed implant• Split ridge technique
  • 166. Study source? ikassem@dr.com
  • 167. Contemprary Oral & maxillofacial surgeryChapter 13 ikassem@dr.com
  • 168. Thank you• You can get it form• http://www.slideshare.net/islamkassem