Hi. This is Dr. Amit T. Suryawanshi. Oral & Maxillofacial surgeon from Pune, India. I am here on slideshare.com to share some of my own presentations presented at various levels in the field of OMFS. Hope this would somehow be helpful to you making your presentations. All the best & your replies are welcomed!

1. Sinus Lift &
Dental Implant Placement.
With Clinical photographs
Dr. Amit T. Suryawanshi
Oral and Maxillofacial Surgeon
Pune, India
Contact details :
Email ID - amitsuryawanshi999@gmail.com
Mobile No - 9405622455

2. Bilateral Maxillary Sinus Lift
• Right side is planned as a staged sinus lift
procedure with the surgical removal of the
second bicuspid
• Left side planned for sectioning of fixed
bridge, removal of fractured premolar, left
antral graft and immediate placement of
three osseointegrated tapered screw vent
implants

3. First Surgical Procedure: Right Side
• This is a 40 year old patient
scheduled for prosthetic
reconstruction of maxillary arch
• Opposing fixed mandibular bridge
work
• No posterior maxillary dentition
• Our goal was to place 2, long,
tapered screw vent implants on the
right side (13mm)
• Implant length is important in
younger patients to insure long term,
proper function against opposing
fixed bridgework

4. Staged Sinus Lift
• The right side was staged
due to the lack of bone and
the desire to augment the
right antrum with 8-10mm
of bone
• As with all of our bone
grafting procedures, the
grafts are augmented using
platelet concentrate

5. Second Surgery: bilateral procedure
• 2 tapered screw vent implants are placed
into the right antral graft
• On the left side we sectioned the fixed
bridge distil to the maxillary left canine
• The left first bicuspid was surgically
removed
• 3 tapered screw vent implants were
placed in the left quadrant
• The anterior implant was immediately
placed in the extraction site of the first
bicuspid
• An antral sinus lift was performed on the
left side for the posterior implant
• 11.5mm implant placed immediately into
left antral graft

6. Surgical Notes
• Notice complete osseous
healing of buccal window 4
months after staged antral
graft on the right side
• The right sinus lift graft
enabled the placement of a
4.7, 13mm & 3.7, 13mm
implants into the second
bicuspid and first molar
sites

7. Surgical Notes
• Note buccal defect associated
with anterior implant placed
immediately into the first
bicuspid extraction site
• Sinus window and schneiderian
membrane visible with parallel
pin in distil implant site
• Graft applied to left antrum as
well as buccal defect
• Note the neat isolation and
containment of graft material due
to the use of platelet rich plasma

8. Final Notes
• Note radiopaque areas in
the right and left sinus
cavities indicating
organization and
ossification of sinus grafts
• This patient was treated in
2 efficiently planned
surgical procedures with
the aid of general
anesthesia

9. Basic Surgical Techniques for
Endosseous Implant Placement

10. 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).

11. History of Dental Implants
In 1952, Professor Per-Ingvar Branemark,
a Swedish surgeon, while conducting research
into 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".

12. First Implant Design by Branemark
All current implant
designs are
modifications of this
initial design

13. Surgical Procedure
STEP 1: INITIAL SURGERY
STEP 2: OSSEOINTEGRATION PERIOD
STEP 3: ABUTMENT CONNECTION
STEP 4: FINAL PROSTHETIC
RESTORATION

14. Fibro-osseous integration
• Fibroosseous integration
– “tissue to implant contact with dense collagenous
tissue between the implant and bone”
• Seen in earlier implant systems.
• Initially good success rates but extremely
poor long term success.
• Considered a “failure” by todays standards

16. 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

17. 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.

18. 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

20. Subperiosteal

21. Transmandibular Implant

24. Blade Implant

25. Endosteal Implants

26. The “Parts”
• Implant body-fixture
• Abutment (gingival/temporary healing vs.
final)
• Prosthetics

27. Clinical Components

28. abutment

29. Team Approach
• A surgical – prosthodontic consultation is
done prior to implant placement to address:
– soft-tissue management
– surgical sequence
– healing time
– need for ridge and soft-tissue augmentation

30. Clinical Assessment
• Assess the CC and Expectations
• Review all restorative options:
– Risks and Benefits
• Select option that meets functional and
esthetic requirements

31. Patient Evaluation
• Medical history
– vascular disease
– immunodeficiency
– diabetes mellitus
– tobacco use
– bisphosphonate use

32. 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

33. Surgical Phase- Treatment Planning
• Evaluation of Implant Site
• Radiographic Evaluation
• Bone Height, Bone Width and Anatomic
considerations

34. Basic Principles
• Soft/ hard tissue graft bed
• Existing occlusion/ dentition
• Simultaneous vs. delayed reconstruction

35. 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

36. Anatomic Considerations
• Ridge relationship
• Attached tissue
• Interarch clearance
• Inferior alveolar nerve
• Maxillary sinus
• Floor of nose

37. Radiological/Imaging Studies
• Periapical radiographs
• Panoramic radiograph
• Site specific tomograms
• CAT scan (Denta-scan, cone beam CT)

38. Width of Space and Diameter of Implant
Attention must be paid to both the coronal and
interradicular spaces

40. A case against routine CT
• Expense
• Time consuming process
• Use of radiographic template/proper fit
requires DDS present
• Contemporary panoramic units have
tomographic capabilities
• Usually adds no additional data over
standard database

43. Image Distortion

44. Anatomic Limitations
Buccal Plate 0.5mm
Lingual Plate 1.0 mm
Maxillary Sinus 1.0 mm
Nasal Cavity 1.0mm
Incisive canal Avoid
Interimplant distance 1-1.5mm
Inferior alveolar canal 2.0mm
Mental nerve 5mm from foramen
Inferior border 1 mm
Adjacent to natural tooth 0.5mm

45. Dental Implant Surgery Phase I
• Aseptic technique
• Minimal heat generation
– slow sharp drills
– internal irrigation?
– external cooling

46. Dental Implant Surgery Phase I
• Adequate time for integration
• Adequate recipient site
– soft tissue
– bone
• Kind & Gentle technique

56. Disposition
1. Chlorhexidine
2. Analgesics
+/- antibiotics

57. Implant placement 3 months after menton bone
grafting

60. Exposure of Implant during
Placement

63. Summer’s Osteotomes

64. Limitations to Implant placement in the
Maxilla
• Ridge width
• Ridge height
• Bone quality

65. Surgical Solutions to Anatomical
Limitations
Onlay Bone Graft Sinus Lift

66. Summers, RB. A New concept in Maxillary
Implant Surgery: The Osteotome technique.
Compendium. 15(2): 152, 154-6
• Ridge expansion technique
– 3-4 mm of crestal alveolar width
required
• Sinus floor elevation technique
– 8-9 mm of alveolar bone height
required in order to place a 13 mm
implant
(4-5 mm sinus floor elevation)

68. Introduction
Ridge expansion technique
• 1.6 mm pilot hole
• Summers osteotome # 1-4
– sequenced tapered osteotomes.
– ridge expansion (displacement) versus
bone removal.
• Final drill coincident with the final
implant size (sometimes not
necessary)

70. Introduction
Sinus floor elevation technique
• 1.6 mm pilot hole
• Summers osteotome # 1-4
– Sinus floor microfractured superiorly
– Sinus floor can be elevated 4-5 mm
– May backfill with bone allograft/alloplast
• Final drill coincident with final
implant size

72. Surgical Technique

74. A. Rake, K. Andreasen, S. Rake, J. Swift A Retrospective
Analysis of Osteointegration in the Maxilla Utilizing an
Osteotome Technique versus a Sequential Drilling
Technique, 1999 AAOMS Abstract
• 155 maxillary implants in 84 patients restored
for at least 6 months
– 57 were placed utilizing the osteotome technique
– 98 were placed utilizing the drilling technique
• One implant failed of the 98 in the drill group
• None of the implants had failed of the 57 in the
osteotome group

75. Stage II Surgery Preoperative
Considerations
• 3-6 months after stage I

76. Stage II Surgery Preoperative
Considerations
• Done under local anesthesia
• Pre-op medications
– Chlorhexidine rinse

79. Placement of
healing abutment

86. conclusions
• The failing implant is very difficult to treat
• Traumatic surgical manipulation with
initial instability of implant increases risk
of failure
• Implant success is only as good as the
prosthodontic reconstruction