Implant surgeries to overcome anatomic difficulties/certified fixed orthodontic courses by Indian dental academy

IMPLANT SURGERIES TO
OVERCOME ANATOMIC
DIFFICULTIES
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

CONTENTS
 INTRODUCTION
 GUIDED TISSUE REGENERATION.
 RIDGE AUGMENTATION.
 MAXILLARY SINUS LIFT TECHNIQUE
 INFERIOR ALVEOLAR CANAL LATERALIZATION
 MENTAL NERVE DISTALIZATION
 CONCLUSION
 BIBILOGRAPHY

INTRODUCTION
The goal of modern dentistry is to restore the patient to
normal contour, function, comfort, esthetics, speech and health
regardless of the atrophy, disease or injury of the
stomatognathic system.
As a result of continued research in treatment
planning, implant designs, materials and techniques
predictable success is now reality for rehabilitation of many
challenging clinical situation.

Various techniques to over come anatomic difficulties
are:
1. Guided tissue regeneration.
2. Ridge augmentation.
3. Maxillary sinus lift technique
4. Inferior alveolar canal lateralization
5. Mental nerve distalization

Guided tissue regeneration :
It is a process used in regeneration of periodontal supporting
structures around natural tooth that have been lost as a result
of inflammatory diseases or trauma - MELCHER

MECHANISM OF GTR

 Barrier to prevent other tissues,
 Provide additional wound coverage, and provide added
stability and protection of the blood clot.
 a tent- like area.

The principles of membrane barrier techniques are to facilitate:
1. Augmentation
2. Improve bone healing
3. complete bone regeneration,
4. Improve bone grafting results, and
5. Treat failing implants

Indications
 Various implant defects
 Fenestrations
 Dehiscence
 Residual intra osseous defect
 Extraction socket defect

Materials used
 Non-resorbable
1. cellulose filter ( millipore)
2. e-PTFE (goretex)

Resorbable
Degradation through enzymatic activity (biodegradation) or
hydrolization (bioabsorption) as a cellular response from the
surrounding tissue.
They include
1. collagen membranes,
2. polylactic acid,
3. polyglycolic acid,
4. synthetic liquid polymer,
5. polyglactin,
6. calcium sulfate.

RIDGE AUGMENTATION
CAWOOD AND HOWELLS

Aims
Restoration of optimum :
 Protection
 interarch relationship.
 retention and stability
 patient comfort.

Limitations
 .

Graft materials
 Autogenous bone graft – iliac crest, rib grafts
 Allogenic bone grafts – freeze dried cadaver bone.
 Alloplastic material – hydroxyapatite
 Metal mesh with autogenous cancellous bone.
 Metal mesh with hydroxyapatite

MANDIBULAR AUGMENTATION
Augmentation procedures :
1. superior border grafting
2. inferior border grafting
3. interpositional bone graft
4. visor osteotomy
5. onlay grafting.

SUPERIOR BORDER GRAFTING
 Davis
 Two 15 cm autogenous rib grafts

DISADVANTAGES
 Second surgical site necessary.
 Continued resorption of the grafted sites.
 Soft tissue dehiscence or limitation
 donor site morbidity

INFERIOR BORDER GRAFTING
 Indicated when ridge height is less than 5-8mm and risk of
pathological fracture.
 Used for reconstruction of mandible following resection,
augmentation of atropic ridge and subsequent placement of
implants

 Supraclavicular incision from mastoid to mastoid region.

ADVANTAGES
 patient's old dentures can be used as transitional dentures
 11 to 17 mm of bone augmentation
 resorption rate of only 5 per cent over the first several years.
 Increased bone height
 adequate tissue coverage

Interpositional Bone Grafts
 Sandwich Grafting
 a horizontal osteotomy
 In mandible, sandwich technique is
mainly used
 Delivery of the prosthetic appliance is
delayed 3 to 5 months for allowing the
remodeling of the bone.

Advantages
 Less resorption rate than onlay grafting.
 More predictable long-term results.
 Decreased incidence of nerve paraesthesia than the visor
osteotomy.
 Can be used in conjunction with osseointegrated implants.

Onlay Grafting
 Done when adequate height but inadequate width.
 Two techniques
1. Oldest technique

 Advantages
 • Improves the height and width of the
maxillaryalveolar bone
 • Can be used both in the anterior and
posterior region.

Technique 2 :
 .

Visor Osteotomy

Visor Osteotomy
Advantage
Eighty percent of the height is maintained at the end of 3-5
years.
Disadvantages
 Nerve paraesthesia and dysesthesia.
 Need for hospitalization.
 Donor site morbidity.
 Inability to wear the dentures for 3 to 5 months following
surgery.

 Modified Visor Osteotomy
 .

SINUS LIFT TECHNIQUE
 Hilt Tatum. Bob James,
and Phil Boyne, is not the
same procedure
performed today.

 Currently, the procedure that is being performed in contemporary implant
reconstruction for the posterior maxilla is more accurately labele the
maxillary antroplasty with augmentation bone grafting.

INDICATIONS
 Implant placement in areas of insufficient bone volume
 Oroantral fistula repair.
 Alveolar cleft reconstruction.
 Cancer reconstruction for craniofacial prostheses.

GENERAL MEDICAL CONTRAINDICATIONS
1. Radiation treatment to the maxillary region.
2. sepsis
3. Severe medical fragility.
4. uncontrolled systemic disease
5. excessive tobacco abuse
6. excessive alcohol or substance abuse
7. Psycophobias.

LOCAL FACTORS
 Maxillary sinus infections
 Chronic sinusitis
 Odontogenic infections
 Inflammatory or pathologic lesions
 Severe allergic rhinitis

The bone graft material is placed into the sinus.

Category 2 surgery
The newly formed bone, and the elevated sinus floor.

Benefits
 Reconstruct the highly atrophic posterior maxilla
 Replace the patient's removable prosthesis
 Stabilize the anterior residual dentition by reconstructing the
entire arch
 Reduce the continuous progressive atrophy of the posterior
alveolar ridge

complications
Sinus membrane perforation is a complication of
sinus elevation surgery. in this image a small (1-2 mm)
perforation can be observed
A large perforation was created by removal of the
bony window with the underlying sinus membrane. In
a case of such a large perforation, the sinus elevation
procedure should be aborted.

Complications
 Dehiscence with loss of the graft material
 Dehiscence with exposure of the barrier membrane
 Infection
 Potential loss of implants

 GUINDELINES to follow for sinus grafting for dental
implants may also include the following:
 alveolar residual bone height of less than 10mm
 less than 4mm of residual bone width
 no history of pathosis
 No significant history of sinus disease.
 No anatomic limitations presented by anatomic structures or
scarring after previous surgery

 Gaber et al did a study on potential alterations of voice quality
following sinus elevation For the majority of patients, slight
changes of the voice pattern are of no importance. However,
for voice professionals, whose voices have become part of
their distinctive profession or trademark, minimal changes
may have dramatic consequences. This specific group of
patients, such as speakers, actors and singers, depend on the
particular quality and timbre of their voice for their livelihood.

INFERIOR ALVEOLAR NERVE LATERALIZATION

NERVE ANATOMY
 Solar documented Two different types of intraosseous path of
the mental nerve

DISTALIZATION OF THE MENTAL NEUROVASCULAR
BUNDLE

LIMITATIONS
 These procedures are technically difficult and therefore not suited
for every doctor.
 Implant practitioners who have the clinical experience, anatomic
knowledge, and ability to treat potential interoperative and
postoperative complications are the only ones equipped to perform
these procedures.
 Nerve damage is a significant risk of the procedures. Both the
surgical manipulation of the neurovascular bundle and the overall
surgical procedure can cause postoperative nerve deficits.

 Each patient should be advised of the risk for permanent
nerve deficits, which include anesthesia, paresthesia, dyses
thesia, and hyperesthesia.
 Fracture of the mandible, although rare, is also a risk. The
vast majority of these patients have advanced degrees of
atrophy in this area of the mandible.

CONCLUSION
Patients undergoing these procedures usually displays
post operative neurologic deficiency. Periodic assessment of
these patients are utmost important. Without the benefits of
CT scans and three dimensional reformatted imaging, these
techniques are difficult, if not impossible, to perform.
However, this technology has made these procedures a viable
option when performed by a skilled and knowledgeable
surgeon in appropriately selected cases.

BIBLIOGRAPHY
 Charles A.Babbush: Dental Implants The Art and Science.
 Carl. E. Meish – Implant dentistry
 Block Kent Guerra: Implants in Dentistry Essentials of
Endosseous Implants for Maxillofacial Reconstruction.
 Block: Color Atlas of Dental Implant Surgery.
 Neelima Anil Malik: Textbook of Oral Maxillofacial
Surgery
 Jensen: The Sinus Bone Graft.

 Charles A.Babbush ; Transpositioning and repositioning the
inferior alveolar and mental nerves in conjunction with endosteal
implant reconstruction; Periodontology 2000, Vol. 17, 1998,
183-190
 Ellegaard et al; Implant therapy involving maxillary sinus lift in
periodontally compromised patient; Clin Oral Impl Res
1997;8;305315 .
 Eliaz Kaufman: Maxillary Sinus Elevation Surgery: An
Overview; j Esthet Restor Dent 2003; 15:272283
 Gabor et al: Effects of sinus lifting on voice quality: Clin. Oral
Impl. Res. 14, 2003 / 767–774
.

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