Implants in orthodontics 1 /certified fixed orthodontic courses by Indian dental academy


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Implants in orthodontics 1 /certified fixed orthodontic courses by Indian dental academy

  1. 1. Implants in orthodontics
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education
  3. 3. CONTENTS 1. 2. 3. 4. Introduction . Historical background . Classification of implants . Diagnosis & treatment planning implants . 5. Bone physiology & metabolism . 6. Principles - Osseointegration . 7. Biomaterials in implants . for
  4. 4. 8. Biomechanics in implant dentistry. 9. Complications with implants . 10.Uses of implants - Medical . - Orthodontic . 11. Conclusion .
  5. 5.
  7. 7.  For centuries man has dreamt of replacing missing teeth with artificial substitutes that restore the normal function, comfort, esthetics, & speech.  Implants make that dream come true .
  8. 8. With implants we enter a new era of dental care & oral rehabilitation. They increase the treatment possibilities for patients & improve functional results of the treatment.
  10. 10. Ancient implants – Attempts to replace lost teeth with endosteal implants have been traced to ancient Egyptian & South American civilization. A skull from Pre Columbian era in museum shows an artificial tooth carved from dark stone, replaced a lower left lateral incisor. Implanted animal & carved ivory tooth cited in ancient Egyptian writings are oldest examples of primitive Implantology.
  11. 11.  Earliest dental implants used, were of stone & ivory, cited in archeological records of China & Egypt , before the common era.  Gold & ivory dental implants were used in 16th & 17th century.
  12. 12. Metal implants device of gold , lead, iridium, stainless steel, cobalt alloy were developed in 20th century. Cobalt – chromium – molybdenum subperiosteal & titanium blade implants were introduced in 1940s & 60s respectively & became the most popular & successful implants device from 1950-80 .
  13. 13. Exaggerated claims in the wake of long term morbidity & unpredictability evolved into disbelief & disinterest & even denial on the part of organized dentistry. These implants never really caught.
  14. 14. IMPLANTS Nomenclature & Classification.
  15. 15. Implant-: A dental implant is a device of biocompatible material/s placed within or against the mandibular or maxillary bone to provide additional or enhanced support for a prosthesis or tooth.
  16. 16. Parts of an implant
  17. 17. Gold screw Gold cylinder Abutment Cover screw Fixture
  19. 19. Implants Endosteal Subperiosteal Transosteal Root form Plate/blade form Endodontic stabilizer
  20. 20. Endosteal implant Endo – within Osteal – bone -: alloplastic material surgically inserted into a residual bony ridge, primarily to serve as a prosthodontic foundation.
  21. 21.  Endosteal implants comprise one broad category of implants .  The most commonly applicable abutment providing modalities are endosteal.  The endosteal implants are placed within a fully or partially edentulous alveolar ridges with sufficient residual bone available.
  22. 22. Some endosteal implants are attached to components for the retention of a fixed or removable prosthesis. Other implants are equipped with an abutment integral with the implant body, which protrudes into the oral cavity during healing.
  23. 23. Root form implant  These are designed to resemble the shape of a natural tooth root. They usually are circular in cross section .  As a general rule root form must achieve Osseointegration to succeed. Therefore they are placed in a functional state during healing until they are osseointegrated .
  24. 24. Most of the root forms are 2 stage implants Stage 1 – is submersion or semi submersion to permit a functional healing . Stage 2 – is attachment of an abutment or retention mechanism. A root form can be placed anywhere in the mandible or maxilla where there is sufficient bone available.
  25. 25. Plate / Blade form implant  The basic shape of plate or blade implant is similar to that of a metal plate or blade in cross section . Some plate blade forms have combination of parallel & tapered sides. They are unique among implants in that they can function successfully in either osseointegration or osteopreservation mode of tissue integration.
  26. 26. Plate/blade form implants
  27. 27. Endodontic stabilizer implants
  28. 28. The endodontic stabilizers function in the osteopreservation mode of tissue integration
  29. 29. Subperiosteal implants Because there is often not enough bone in which to place an endosteal implant. Dentists turned to, placing it on & around the bone .
  30. 30. Transosteal implants Surgically invasive & technique sensitive. These implants feature a plate that is placed against the exposed inferior border of the mandible with extension that pass from this plate through symphyseal area out of the crest of the ridge & into the oral cavity.
  31. 31. Ramus frame implants Often intended for treatment of total mandibular edentulism with severe alveolar ridge resorption.
  33. 33. Consultation  Chief complaint  Patients Goals of Treatment
  34. 34. Clinical Examination  Medical examination  Radiography  Diagnostic Models
  35. 35. Diagnosis & Treatment Planning    Periodontics Operative Prosthodontics – Abutment support evaluations  New implant abutment support – Evaluation of available bone  Quality  Quantity – Choice of implant modality  Endosteal - root form - plate / blade form  Subperiosteal  Natural implant abutment support
  36. 36.  Goal-oriented case presentation – Other treatment options – Thoroughly informed consent    Acceptance of treatment plan Treatment Maintenance – Professional maintenance  Recall examination and prophylaxis  Early detection & treatment related complication  Patient education – Home care
  38. 38.  Bone mineral is primary metabolic stores of essential element calcium. In addition to its obvious structural role, bones most primitive & essential function is calcium metabolism.  Phylogenetically the original purpose of internal stores of mineralized tissue was to serve as a physiologic reservoir of calcium.
  39. 39. Bone is a highly ordered composite of organic matrix & inorganic material. Osseous matrix, referred to as osteiod – Before mineralization , is primarily collagen fibers embedded in ground substance. The latter is a viscous gel of water & glycoprotein complex. It also contains numerous organic factors ( cytokines,growth factors)
  40. 40.  During mineralization small crystals of hydroxyapatite are densely packed in an ordered array according to collagen fiber orientation.  Osseous tissue is formed in a number of configuration depending on age , function & physiologic history.  Bones are composed of 4 microscopic tissue types-Woven bone -Lamellar bone -Bundle bone -Composite bone
  41. 41. Woven bone  Highly cellular osseous tissue that is formed rapidly , in response to growth or injury.  Compared to mature bone it has relatively low mineral content, a more random fiber orientation & minimal strength .  This serves an important stabilization role in initial healing of endosseous implant as it is more pliable than mature lamellar bone.  Woven bone lacks the strength to resist functional load.
  42. 42. Lamellar bone Is the principal load bearing tissue of adult skeleton. In adults lamellae are formed slowly , they have highly organized matrix ,& are densely mineralized .
  43. 43. Bundle bone It is the characteristic of ligament & tendon attachment along with bone forming surfaces. Bundle bone is formed adjacent to the periodontal ligament of physiologically drifting teeth.
  44. 44. Composite bone  It is the lamellar bone deposited on woven bone.  Lamellar compaction of the composite bone is an important step in achieving stabilization of an implant during the rigid integration process.
  46. 46. Osseointegration  Osseointegration is a biological concept . It refers to the incorporation within living bone of an inanimate (metallic component) . It is in essence an anchorage mechanism , nothing more nothing less.  Osseointegration is defined as direct , structural & functional connection between the organized vital bone & the surface of titanium implant , capable of bearing the functional load. – Branemark.
  47. 47. Osseointegration was introduced in dentistry & orthopedics to provide an anchorage system for the prosthesis, the use of osseointegration has broad application – Dental prosthesis. Maxillofacial prosthesis. Injured joint replacement. Artificial limb replacement.
  48. 48. Besides restoration of lost tooth, implant can be indicated as anchorage for orthodontic movement of natural tooth . Orthodontic tooth movement is restricted by reciprocal forces of action / retention when there are no fixed anchorage points in the oral cavity, normally this is compensated for with extraoral anchorage system.
  49. 49. According to Higuchi & Stalk orthodontic forces of 150 -400 gms can be applied to implants during orthodontic treatment which allows tooth movement without affecting osseointegration.
  50. 50. Fibrointegration Osseointegrtion
  52. 52. Biocompatibility It is defined as an appropriate response to a material (biomaterial) within a device (design) for a specific clinical application.
  53. 53. In 1960’s emphasis was placed on making biomaterial more inert & chemically stable within the biologic environment. High purity ceramics of aluminum oxide, carbon, carbon- silicon compound are classical examples of these trends.
  54. 54. In 1970’s – Biocompatibility was defined in terms of minimum damage to the host or the biomaterial. In 1980’s – Focus transferred to bioactive substrates intended to positively influence tissue response .
  55. 55. In 1990’s – Emphasis has been on chemically & mechanically anisotropic substrates combined with growth (mitogenic) & inductive (morphogenic) substances.
  56. 56. characteristics of implant material Physical & mechanical properties – Forces exerted on implants consists of – Tensile Compressive Shear components.
  57. 57. Parafunction can be greatly detrimental to longivity because of mechanical properties like –  Maximal yield strength .  Fatigue strength .  Ductility.  Creep deformability &  Fracture.
  58. 58. As bone can modify its structure in response to forces exerted on it , implant material must be designed to account for increased performance of musculature & bone, in jaws restored with implants .
  59. 59. Corrosion & biodegradation – Corrosion is a special concern for metallic materials, in dental Implantology because implants protrude into the oral cavity where electrolyte & oxygen composition differ from that of tissue fluids.
  60. 60. Stress corrosion cracking – The combination of high magnitude of applied mechanical stress & simultaneous exposure to a corrosive environment can result in the failure of metallic implant materials by cracking.
  61. 61. Toxicity – Is related to primary biodegradation products (simple & complex cations & anions) , particularly those with higher atomic weight metals.
  62. 62. Metals and alloys as implants.  Titanium  Titanium- 6 aluminum-4 vanadium  Cobalt- chromium –molybdenum based alloys.  Iron –chromium –nickel based alloys.  Ceramics & carbon – - Aluminum , titanium & zirconium oxides.  Bioactive & biodegradable ceramics based on calcium phosphates.  Polymers & composites.
  64. 64. The Discipline of biomedical engineering & application of these principles to living systems has unfolded a new era in diagnosis, treatment planning & rehabilitation in patient care. BIOMECHANICS
  65. 65. Loads applied to dental implants Dental implants are subjected to occlusal loads when placed in function , which may vary dramatically in magnitude, frequency,& duration depending on patients parafunctional habits.
  66. 66. Passive mechanical load  During the healing stage because of the mandibular flexure, contact with first stage screw .  Perioral forces of tongue ,cheek exert low but frequent horizontal loads on implant abutment .  These may be of greater magnitude with parafunctional oral habit or tongue thrust.
  67. 67. Forces  Forces may be described by magnitude, direction, duration & magnification factors.  Forces acting on a dental implant are referred to as vector quantities i.e they possess both magnitude & direction.  A force applied to a dental implant is rarely directed absolutely longitudinally along a single axis. In fact 3 dominant clinical loading axes exist in implants –  Mesiodistal.  Faciolingual.  Occlusoapical.
  68. 68.
  69. 69. Components of forces Occlusion serves as a primary determinant in establishing load direction. Angled abutments also results in development of dangerous transverse force components under occlusal loads , in the direction of the angled abutment.
  70. 70. 3 types of forces – 1. Compressive. 2. Tensile. 3. Shear . Compressive – compressive force tends to maintain the integrity of a bone to implant interface .
  71. 71.  Tensile & shear forces tend to distract or disrupt such an interface.  Shear forces are most destructive to implant & / or bone when compared to other load modalities.  Compressive force are best accomodated.
  72. 72. Cortical bone is strongest in compression & weakest in shear. Implant body design transmit the occlusal load to the bone. The conversion of a single force into 3 different types of forces is completely controlled by the implant geometry .
  73. 73.  Cylinderic implants in particular are at highest risk for harmful shear loads at the implant to tissue interface under an occlusal load directed along the long axis of the implant body.  Bone loss adjacent to cylindrical implant and / or coating degradation results in mechanically compromised implant.
  74. 74. Stress The manner in which the force is distributed over a surface is referred to as mechanical stress. The magnitude of stress is dependent on 2 variables – 1. Force magnitude . 2. Crossectional area over which force is dissipated.
  75. 75. Force magnitude  Rarely can be controlled.  May be decreased by decreasing the magnifiers of force – 1. cantilever length 2. off set bends 3. crown height 4. Night guards nocturnal parafunction.
  76. 76. Functional cross sectional area Defined as the surface that participates significantly is load bearing & stress dissipation it may be optimized by – 1. no. of implants in given edentulous area. 2. Selecting an implant geometry . Increase in functional surface area serves to decrease magnitude of mechanical stress.
  77. 77. Strain & deformation Load applied to a dental implant may induce deformation of both implant & surrounding tissue. Biologic tissue may be able to interpret deformation or a manifestation & respond with initiation of remodeling activity.
  78. 78. Impact loads  When 2 bodies collide in a very small interval of time relatively large reaction force develops . Such a collision is described as impact.  The higher the impact load greater is the risk of implant failure & bone fracture.  Rigidly fixed implants generate a higher interfacial impact force with occlusion compared with natural teeth , which possess periodontal ligament.
  79. 79. Force delivery & fatigue mechanism Duration of force may effect the ultimate outcome of an implant system. Relatively low magnitude forces applied repeatedly over a long time ,may result in fatigue failure of an implant / prosthesis.
  81. 81. Soft tissue complications Infection Exposure of cover screw. Gingivitis. Exposure of the fixture threads.
  82. 82. Bone complications Progressive marginal bone loss – 1 – 1.5mm 1st yr. of surgery. occlusal trauma. fixture fracture. Fixture mobility – If fixture mobility is detected, regardless of degree of mobility it is considered as failure to osseointegrate.
  83. 83. Treatment – Fixture must be extracted. Possible causes of failure can be –  During 1st stage of surgery - tissue bed damaged by thermal changes.  During healing phase – inflammation.  Prior to healing – occlusal or traumatic forces.  Progressive gingivitis – inhibits osseointegration.  Bony thread fracture in fixture site.
  85. 85. Incision
  86. 86. Mucoperiosteum raised Neurovascular bundles
  87. 87. Perforation of the cortex Preparation of the site
  88. 88. Preparation of site Insertion of the implant
  89. 89. Implants placed suturing
  90. 90. Location of the implants Healing abutments
  91. 91. Cover screws exposed through punch incision Healing abutments inserted
  92. 92. Healing abutments removed to reveal peri implant cuff. Assessment of soft tissue depth
  93. 93. Abutments Abutments
  94. 94. Final abutments
  97. 97. Congenitally absent ear
  99. 99.
  101. 101. Pre-treatment Implant with bar Post-treatment
  103. 103. Pre-treatment Pre-treatment Posttreatment
  105. 105. Ocular prosthesis
  107. 107. Pre-treatment Endosseous implant Post - treatment
  108. 108. Rigid Implant Anchorage to Close a Mandibular First Molar Extraction Site W. EUGENE ROBERTS, CHARLES L. NELSON, CHARLES J. GOODACRE,
  109. 109. Age = 34 year Sex = Male Class I mutilated malocclusion Missing: maxillary right first and mandibular left first permanent molars  Treatment : Implant-supported anchorage  Tx planning : non-extraction  to close the asymmetric first molar extraction  unidirectional (mesial) space closure.    
  110. 110. Pre-treatment
  111. 111.
  112. 112.
  113. 113.
  114. 114. $ Post-treatment
  115. 115. Facial implants
  116. 116.
  117. 117. The use of implants for orthodontic correction of an open bite
  118. 118.  Age / sex – 25 yrs./ male  A traumatic injury to the anterior mandible.  A panoramic radiograph revealed nondisplaced horizontal and vertical fractures of the mandibular anterior alveolar processes. with displacement of lower right incisors, canine, and premolar. The lower left incisors were avulsed at the time of trauma.  Treatment 3 implants in the mandibular central, left canine, and premolar regions. replace missing teeth with a fixed prosthesis, orthodontic correction.
  119. 119. Pre-treatment
  120. 120. TREATMENT PROGRESS Diagnostic work-up implants were placed Active orthodontic treatment vertical elastics in anterior region and left posterior region Toward the completion anterior open bite closed to 2 mm posterior interdigitation, Class I canine & left side molars in Class I & class II on right side.
  121. 121. Diagnostic set up
  122. 122.
  123. 123.
  124. 124. Post-treatment
  125. 125. Implants as anchorage for molar uprighting and intrusion W. Craig Shellhart, DDS, MS; Maged Moawad, DDS, MPh, MS; Preston Lake, DMD
  126. 126.  Age / sex - 25yrs/ male  chief complaint - Anterior and posterior crossbites.  I/o An anterior crossbite, left maxillary lateral incisor positioned lingually. Reduced overbite . The left posterior teeth were in a crossbite, maxillary arch - transverse asymmetry mandibular first molars missing bilaterally.  Diagnosis - (Class I skeletal, normal incisor angulation, normal vertical relations).
  127. 127. Pre-treatment
  128. 128. Pre-treatment
  129. 129. Treatment plan use of osseointegrated implants. TPA Mandibular second molars to be tipped distally & intruded. allow the placement of single tooth prostheses bilaterally.
  130. 130.
  131. 131. Post-treatment
  132. 132. Post-treatment
  133. 133. Use of maxillary intraosseous implants for Class II elastic anchorage Nile A. Sorenson, Jr, DMD
  134. 134.  Age / sex - 39yr / female  I/o maxilla – missing - incisors & canines & 3rd molars. moderate spacing adjacent to both mandibular canines. The mandibular incisors and canines were over erupted and nearly in contact with the soft tissue on the upper arch - accentuated curve of Spee. A Class II M.R left side. The mandibular midline have shifted 2 mm to the left.
  135. 135. Pre-treatment with RPD
  136. 136. Pre-treatment
  137. 137. With implant
  138. 138. With prosthesis
  139. 139. Bite opened
  140. 140. Bridge in place
  141. 141. Post-treatment
  142. 142. Prediction of mandibular growth rotation A. Björk, Odont. Dr.
  143. 143. It comprised study of 100 children of each sex covering the age period from 4 to 24 years. The sample consists of normal children with and without malocclusion and also children with pathologic conditions.
  144. 144. A growth analysis consists essentially of three items, each of which is clinically significant: 1. An assessment of the development in shape of the face which, in the first place, implies changes in the intermaxillary relationship. 2. An assessment of whether the intensity of the facial growth in general is high or low. 3. An evaluation of the individual rate of maturation. This is important in establishing whether puberty has been reached and when the growth may be expected to be completed.
  145. 145. Structural signs of growth rotation 1) 2) 3) 4) 5) 6) 7) inclination of the condylar head. curvature of the mandibular canal. shape of the lower border of the mandible inclination of the symphysis. interincisal angle. interpremolar or intermolar angles. anterior lower face height.
  146. 146. Osseointegrated titanium, implants for maxillofacial protraction in monkeys
  147. 147. Large dots implants
  148. 148. Extra oral traction appliance
  149. 149. Tracings solid lines – pre treatment dotted lines – post treatment
  150. 150. Solid line – end of force application Dotted line – after 4 weeks Solid line – end of retention Dotted line -10 weeks post retention
  151. 151. Protraction force applied to splinted maxillary teeth Skeletal remodeling & sutural expansion
  152. 152. Zygomatico-temporal suture in control animal Zygomatico-temporal suture in experimental animal
  153. 153. Traction force delivered to maxillary implant. separation of zygomaticomaxillary suture Traction force delivered to zygomatic implant. separation of zygomaticotemporal & suture
  154. 154. Traction force delivered to maxillary dentition minimal effect on zygomatico maxillary suture Traction force delivered to maxillary implant. separation of zygomaticomaxillary suture
  155. 155.
  156. 156. Forced eruption and implant site development: Soft tissue response Theo Mantzikos, DMD, and Ilan Shamus, DDS
  157. 157.  A nonsurgical technique for increasing the amount of available bone for implant site development and fixture placement is orthodontic extrusion, or forced eruption.  when tension is applied to the periodontal ligament, periodontal fiber bundles are elongated, and osteoblasts are induced to deposit new bone in the areas of the alveolus where periodontal attachment exists.
  158. 158. Pre-treatment Bone-loss
  159. 159. Fixed appliance .018 s.s with step down bend
  160. 160. Keratinized gingiva bracket placement on cementum
  161. 161. Vertical bone improvement
  162. 162. CONCLUSION
  163. 163. The last decade has seen implant to be the answer to many problems that dogged the medical profession. Manna from heaven. Add to this the conspicuous studies that metallurgy has made & the gains that will be seen the even better & varied application of implants.
  164. 164. THANK YOU Leader in continuing dental education