Implants /certified fixed orthodontic courses by Indian dental academy


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Implants /certified fixed orthodontic courses by Indian dental academy

  1. 1. Classification, Type of Fixtures Sterilization and Passivation
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education
  3. 3. Contents  Introduction  Definition  Rationale for Dental Implant Design  Classification  Type of Fixtures (Implant body)  Commonly used Endosseous Implant System  Sterilization and Passivation
  4. 4. Introduction  Over the past 20 years, Dental Implants have undergone remarkable changes. Many clinicians designed implants to fit certain needs and properties. Some of those designs had only a short application period, whereas others survived to this very day. Dental implants vary in several aspects, such as shape, place of anchorage (within the bone or on top of the bone), composition, coatings, etc.
  5. 5. Classification: Implants are classified into three basic categories : Endosseous Implants (in bone) Subperiosteal Implants (through bone) Transosseous Implants (on bone)
  6. 6. Endosseous Implants :  are implants that are surgically inserted into the jawbone. They are further classified into :  Ramus form  Pin Form • Disk Form  Plateform Concept  Cylindrical Or Root form Concept
  7. 7. Ramus Concept  The ramus blade originated in late 1960s .  It is now made of grade 2 CP titanium and used as posterior support for a mandibular fixed partial denture when insufficient height and width exit in body of the mandible.  The implant remain unloaded until proper osseous healing occurs.
  8. 8. Pin Concept   This concept originated with J. Scialom in 1950s and was popularized by Michelle. This implant was originally made of tantulum, but now titanium alloy is used in.
  9. 9. Disk Concept  This implant originated with Dr. G. Scorteci of France in 1970s.  The unique two stage design resembles an 18th century candle stick , and uses a facial or buccal placement with special osteotomes.
  10. 10. Plateform Concept   This implant also originated with Dr Harold and Ruberts in late ’60s. Many design variations exit, and commercial sources stock one and two stage protected healing types whether single tooth, single or double headed, maxillary or mandibular versions.
  11. 11. Cylindrical or Root Form Concept  The concept has evolved over centuries with earlier crude forms.  These implants come in a variety of shapes, sizes, and materials and are being offered by many different companies worldwide  Cylindrical Root Form depend on a coating to provide microscopic retention and/or bonding to bone and are usually pushed or tapped into bone site.
  12. 12. Implant body / fixture : referred as surgically placed part which goes either into or set on the top of the jaw bone. 
  13. 13. Parts of Fixtures  Components of the Implant Body may be separated into    A crest module A body An apex region
  14. 14. A SCIENTIFIC RATIONALE FOR ROOT FORM DENTAL IMPLANT DESIGN  Dental implants function to transfer load to surrounding biologic tissues. Thus the primary functional design objective is to manage (dissipate and distribute) biomechanical load to optimize the implant supported prosthesis function.  Biomechanical load management is dependent on two factors:   the character of the applied force and the functional surface area over which the load is dissipated.
  15. 15. CHARACTER OF FORCES APPLIED TO DENTAL IMPLANTS  Stress and strain have been shown to be important parameters for crestal bone maintenance and implant survival. These factors may be measured and compared for different implant body designs.  Forces applied to dental implants may be characterized in terms of five distinct, although related, factors : magnitude, duration, type, direction, and magnification. Each factor must be carefully considered, with appropriate weight, in the critical analysis of implant design.
  16. 16. 1. Force Magnitude  Physiologic    Constraints On Implant Design. Normal physiology imposes constraints on the magnitude of forces that must be withstood by engineering designs in the oral environment. The magnitude of bite force varies as a function of anatomic region and state of the dentition. Following sustained periods of edentulism, the bone foundation often becomes less dense. Its ultimate strength is highly dependent on its density.
  17. 17. As such, less dense bone may no longer be able to support normal physiologic bite forces on implants.  So careful treatment planning, including appropriate implant design selection, is impera­tive to lower the magnitude of loads imposed on the vulnerable implant-to-bone interface. 
  18. 18. 2. Force Duration  Physiologic  Constraints on Design The duration of bite forces on the dentition has a wide range. Under ideal conditions, the teeth come together during swallowing and eating for only brief contacts. The total time of those brief episodes is less than 30 minutes per day. Patients who exhibit bruxism, clenching, or other parafunctional habits, however, may have their teeth in contact several hours each day.
  19. 19. 3. Force Type  Physiologic Constraints on Design  Three types of forces may be imposed on dental implants within the oral environment: compression, tension, and shear. Bone is strongest when loaded in compression, 30% weaker when subjected to tensile forces, and 65% weaker when loaded in shear .  Endosteal root­form implants load the bone­ to­implant interface in pure shear (e.g., a smooth sided cylinder) unless surface features are incorporated in the design to transform the shear loads to more resistant force types.
  20. 20.  Influence  on Implant Body Design A smooth cylinder implant body results in essentially a shear type of force at the implant­to­bone interface. Thus this body geometry must use a microscopic retention System by coating the implant with titanium or hydroxyapatite.  Threaded implants have the ability to transform type of force imposed at the bone interface through careful control of thread geometry. Thread shape is particularly important in
  21. 21. Thread shapes in dental implant designs includes :    square V-shape buttress
  22. 22.  Under axial loads, to a dental implant, a V -thread face (typical of Paragon,3i and Nobel Biocare) is comparable to the buttress thread (typical of SteriOss) when the face angle is similar and has approximately a 10 times greater shear component of force than a square or power thread (typical of BioHorizons).
  23. 23. 4. Force Direction  Physiologic   Constraints on Design The anatomy of the mandible and maxilla places significant constraints on the ability to surgically place root form implants suitable for loading along their long axis. Resorptive patterns following prolonged edentulism exacerbates the normally occurring angulation challenges . Bone is strongest when loaded in its long axis in both compression or tensile forces. A 30-degree offset load reduces the compressive strength of bone by 11%, and reduces the tensile strength by 25%.
  24. 24.  Influence  on Implant Body Design As the angle of load increases, the stresses around the implant increase, particularly in the vulnerable crestal bone region. As a result, virtually all implants are designed for placement perpendicular to the occlusal plane. This place-ment allows a more axial load to the implant body and reduces the amount of crestal stress. Additionally, axial alignment places less stress on the abutment components and decreases the risk of short- and long-term fracture.
  25. 25. The face angle of the thread or plateau can change the direction of load from the prosthesis to abutment connection, to a different force direction at the bone.   As a result, the axial load on the implant platform may be a compressive load, but the 30degree angle of the V -shape thread can reduce the amount of load the bone interface is able to resist. The power thread design can take the axial load of the prosthesis to abutment connection and transfer a more axial load along the implant body to compress the bone, rather than convert it to 10 times more shear.
  26. 26. 5. Force Magnification A surgical placement resulting in extreme angulation of the implant and/or a patient exhibiting parafunctional habits will likely exceed the capability of any dental implant design to withstand physiologic loads.  Cantilevers and crown heights act as levers and therefore are, force magnifiers.  Careful treatment planning with special attention to the use of multiple implants to increase functional surface area is indicated when a clinical case presents the challenge of force magnifiers.
  27. 27. Surface area For a given bone (and implant) volume, implant surface area must be optimized for functional loads.  Thus an important distinction is made between total surface area and functional surface area. 
  28. 28.  Functional surface area is defined as the area that actively serves to dissipate compressive and tensile non-shear loads through the implant-to-bone interface and provide initial stability of the implant following surgical placement.  Total surface area may include a "passive" area that does not participate in load transfer  For example, plasma spray coatings are often reported to provide' up to 600% more total surface a however, the amount of area that is actually exposed to bone for compressive or tensile loading may be less than 30% of the total surface area.
  29. 29. Design Variables in Surface Area Optimization Implant Macro geometry    Smooth-sided, cylindric implants provide ease in surgical placement however; the bone-to-implant interface is subjected to significantly larger shear conditions. In contrast, a smooth-sided, tapered implant allows for a component of compressive load to be delivered to the bone-to-implant interface, dependent upon the degree of taper.
  30. 30. Implant Width  Over the past five decades of endosteal implant history, implants have gradually increased in width.  Today, dental implants generally have reflected the scientific principle that an increase in implant width adequately increases the area over which occlusal forces may be dissipated. For root form implants of circular cross-section, the load bearing area of the abutment platform increases as a function of the radius squared.   A 4-mm root form implant has 33% greater surface area than a 3-mm root form implant.
  31. 31.  Thread  Geometry Functional surface area per unit length of the implant may be modified by varying three thread geometry parameters:    Thread pitch, Thread shape Thread depth.
  32. 32.  Thread Pitch is defined as the distance measured parallel with its axis between adjacent thread forms  Or the number of threads per unit length in the same axial plane and on the same side of the axis
  33. 33. The thread shape is another very important characteristic of overall thread geometry. As described previously, thread shapes in dental implant designs include:    Square  provides an optimized surface area for intrusive, compressive load transmission V-shape  the V -thread design is called "fixture" and is primarily used for fixturing metal parts together-not load transfer. Buttress  is optimized for pullout loads
  34. 34. Differences in shear loading on the standard V-thread and the square thread   V-thread has 10 times greater shear loads on bone compared with a square thread The reduction in shear loading at the thread-tobone interface provides for more compressive load transfer, which is particularly important in compromised D3 and D4 bone.
  35. 35. The thread depth refers to the distance between the major and minor diameter of the thread.  Conventional implants provide a uniform thread depth throughout the length of the implant.  This unconventional design feature results in dramatic increases in functional surface area at the crest of the bone, where the stresses are highest. 
  36. 36. Implant Length  As the length of an implant increases, so does the overall total surface area. As a result, a common idea has been to place an implant as long as possible preferably, into the opposing cortical plate.  Attempting to engage the opposing cortical plate and preparing a longer osteotomy may result in overheating the bone.  Longer implants have been suggested to provide greater stability under lateral loading conditions.
  37. 37.  Studies have shown that the highest stresses were observed in the crestal bone regions, regardless of the implant length.  This biomechanical analysis supports the opinion- that longer implants are not necessarily better.  Instead, there is a minimum implant length for each bone density, depending on the width and design.  The softer the bone, the greater the length suggested.
  38. 38. Crest Module Considerations  The crest module of an implant body is the transosteal region from the implant body and characterized as a region of highly concentrated mechanical stress.  Instead, it is a transition zone to the loadbearing structure of the implant body  In. fact, bone loss has been observed so often, many implant crest modules are designed to reduce plaque accumulation once bone loss has occurred
  39. 39.   A smooth, parallel-sided crest module will result in shear stresses in this region, making maintenance of bone very difficult. An angled crest module of more than 20 degrees, with a surface texture that increases bone contact, will impose a slight beneficial compressive component to the contiguous bone and decrease the risk of bone loss.
  40. 40. Apical Design Considerations  Most root form implants are circular in crosssection. This permits a round drill to prepare a round hole, precisely fitting the implant body.  Round cross-sections, however, don’t resist torsional/shear forces when abutment screws are tightened or when free-standing, single tooth implant receive a rotational (torsional) force.
  41. 41.  As a result, an anti-rotational feature is incorporated, usually in the apical region of the implant body, with a hole or vent being the most common design.  The apical hole region may also increase the surface area available to transmit compressive loads on the bone.
  42. 42. Surface Coatings  Titanium Plasma Spray Hydroxyapatite Coatings The clinical advantages of TPS or HA coatings may be summarized as the following:     Increased surface area ( can be up to 600%) Increased roughness for initial stability Stronger bone-to-implant interface Additional advantages of HA over TPS include the following:     Faster healing bone interface Increased gap healing between bone and HA Stronger interface than TPS Less corrosion of metal
  43. 43. Disadvantages of coatings include 1. Flaking, cracking, or scaling upon insertion 2. Increased plaque retention when above bone 3. Increased bacteria and nidus for infection 4. Complication of treatment of failing implants 5. Increased cost
  44. 44.   The present designs fall into four morphological categories:  Screw or Threaded  Bullet or Conical  Basket or Vented  Fin or Plateau Others are:  Titanium plasma sprayed screw implant system  Cylindrical Hydroxyapatite coated implant  Grooved Hydroxyapatite coated cylinder  Vitreous carbon implants
  45. 45. Root form Implants contd…     Screw root forms are threaded into bone site and have macroscopic retentive elements for initial bone fixation. Three basic screw thread geometries exist: V- Thread Buttress thread Power thread design
  46. 46.  Screw type of implants have been used for more than two decades.  Earlier placement technique resulted in traumatic site preparation of bone and immediate or early loading of the implant that interfered with bone healing.  Branemark showed 2 keys to predictable screw implant technique and success: avoid traumatizing and overheating the bone during site preparation and allow adequate time for bone healing.
  47. 47.  Almost all commercially available screw-type implant systems recommend not to loading the implant for several months to allow osseointegration to occur.  The only system that still recommends immediate loading of the implants is the titanium plasma sprayed screw system (TPS screws).  Diferent surface finishes range from machine tooled, sand blasted, acid etched, to hydroxylapatite coated; an implant design can range from self tapping to those needing threads cut into the bone.
  48. 48. Screw Root Form contd….,  Branemark Standard Fixture  Branemark Self tapping Fixture  Fixture (Impla-med)  Self tapping fixture (Impla med)  Osseo-Dent (Collagen)
  49. 49. Screw Root Form contd….,     Screw Vent (Core-Vent) Swede Vent (Core-Vent) Swede Vent CST (Core-Vent) Swede Vent CST/HA  Thread provides mechanical interlock with thick labial and lingual cortical plates.  Apical threads engage cortical bone on inferior border.
  50. 50. Screw Root Form contd….,  Steri OSS standard  Steri OSS mini  Steri OSS HA
  51. 51. Screw root form contd…  ITI solid screw (Straumann Inc )  Osteo implant (OIC)  Star-vent  Star-vent TPS
  52. 52. Cylindrical Bullet IMZ (Interpore Intl.)  IMZ-HA (Interpore Intl.)  Integral (Calcitek)  Steri-OSS  Biovent(Core vent)
  53. 53. Cylindrical-Bullet  Hahn Ridgelock (Steri-OSS)  Osseolite (Collagen)  Anchor (Anchor)  Osteoimplant (HA by Impla med)
  54. 54. Cylindrical Basket  The hollow basket design provides nearly twice the bone contact of a solid cylinder of the same length and diameter.  The receptor site is prepared with trephines, producing minimal bone destruction and leaving a vital bone core over which the implant is seated.  Perforations in the cylinder walls enable bone growth through the implant to increase stability and improve load distribution.
  55. 55. Cylindrical Basket contd…..  Titanium or titanium alloy is used, permitting osseointegration. The fenestrated hollowcylinder design minimizes stresses within the implant on vertical loading and providing a greater area for load transmission to the surrounding bone.  Two system currently incorporate the hollowbasket concept:  The ITI implants  The Core-Vent implant
  56. 56. Cylindrical Basket      The ITI implants are made from CP titanium, have a titanium plasma-sprayed surface and promote increased bone contact by increasing the surface area by 6 fold. Were previously provided in several designs – designated as C,E,F,H and fit alveolar ridges of varying ht. and width. ITI hollow Cylinder ITI 150 offset Hollow Cylinder
  57. 57. Cylindrical Basket  Core-Vent basket design combines a superior threaded screw section with an inferior hollow vented basket.  The self tapping threaded neck provides initial stability to help prevent micro movement during healing.  Within the superior threaded region there is a hexagonal-threaded chamber that extands downward towards the basket area but does not communicate with it.
  58. 58. Cylindrical Basket    The Core-Vent implant is manufactured in two diameters: 3.5 and 4.5 mm The threaded portion adds 0.8 to overall dimension, creating outsides dia of 4.3 and 5.3 respectively Four length available are 16, 13, 10.5, and 8 mm
  59. 59. Cylindrical Fin  Finned or serrated root form implants can offer advantages in certain clinical situations.  These implants sometimes called plateau implants have a series of circumferential fins spaced along the bone interfacing portion of the implant.  They usually provides more functional load bearing surface area for efficient transmittal of occlusal loads than others implants.  Proper socket preparation should result in light friction fit for implant after insertion.
  60. 60. Cylindrical Fin  Omni (Omni Intl)  Miter 2000 (Miter Inc)  Stryker Precision  Stryker Precision/HA  Micro-Vent (Core-Vent)
  61. 61. Titanium Plasma Sprayed Screw Implant  It consist of fine grain titanium particles applied to the cylinder in an argon environment under extremely high temp., pressure and velocity.  It offers an increase in surface area over the smooth surface and, thus also more retention in the bone.  Some research has also shown that initial integration into the host bone is somewhat accelerated through that.  Available in dia of 3.3 & 4 mm and length of 8, 11, 13 & 15 mm.
  62. 62. Titanium Screw Implant with a Hydroxylapatite (HA) coating  Beyond an increase in surface area as compared to smooth surface implants, this surface has also shown to have an accelerated initial integration, which makes it ideal for quick initial post-surgical stabilization in weak bone.
  63. 63. Subperiosteal Implants : Are implants, which typically lie on top of the jawbone, but underneath your gum tissues. The important distinction is that they usually do not penetrate into the jawbone.
  64. 64. Subperiosteal Implants :  Indications… Some conditions that are contraindicated for root and blade form may be indicated such as:  An unusual position of mental foramen  A dehiscence of mandibular canal  Generally atrophic mandible  A mutilated oral condition from extensive surgery  Severe gagging problems 
  65. 65. Maxillary HA-coated subperiosteal implants   Unilateral subperiosteal (Hahn) for FPD Complete subperiosteal (Tatum) for maxillary plateless denture.
  66. 66. CAD-CAM subperiosteal implants   Slice/Stack concept (Techmedica) Negative wax moldepoxy pour concept (Cemax)
  67. 67. Unilateral subperiosteal (HA coated)  Serve as posterior abutments for FPD splinted to canine.
  68. 68. Transosseous Implants:  Are implants, which are similar in definition to Endosseous implants in that they are surgically inserted into the jawbone.  However, these implants actually penetrate the entire jaw so that they actually emerge opposite the entry site, usually at the bottom of the chin.
  69. 69. Transosseous Implants:    Has been used for 22yrs to rehabilate patients with unstable mandibular dentures. Adv are immediate denture placement and function Can perform cosmatic surgery of submental fat pad and chin Transmandibular Implant
  70. 70. Characteristics of six popular cylindrical endosseous dental implant systems 1. 2. 3. 4. 5. 6. Branemark USA,Inc Core-Vent core-Vent Corp Interpore IMZ Integral Clcetek Inc Steri OSS Denar Corp Stryker Precision Stryker inc
  71. 71. Branemark USA,Inc  Advantages     ADA full acceptance (edentulous) and provisional acceptance for all other uses Longest documented research Relatively simple surgery Excellent education availability  Disadvantages    Some sponsors do not allow general practitioners to take surgery course Most expensive system Has only pure titanium implants
  72. 72. Core-Vent (CORE-VENT Corp.)  Advantages        Extensive implant options Extensive Prosthodontics options Simple surgery Lower cost Good education High popularity Sells "Branemark" clone at lower cost  Disadvantages  Complexity of options (both surgical and prosthodontic) requires good organization
  73. 73. Interpore IMZ  Advantages ADA provisional acceptance for all uses. Relatively simple surgery Moderate cost Good education Provides simulated periodontal ligament intramobile eIementIMZ) if desired Pioneer in research on hydroxylapatite coating for faster integration Tissue recession on HA coating leaves polished surface  Disadvantages Intramobile element (IMZ) requires replacement on annual basis
  74. 74. Integral Clcetek Inc  Advantages       ADA provisional acceptance Prosthodontic adaptations relatively good Pioneer in use of hydroxylapatite coating for faster integration Simple surgery Good education Moderate cost  Disadvantages   Standard size and small diameter (SD) require purchase of two separate surgical starter kits Has only hydroxylapatite coated implants
  75. 75. Steri OSS Denar Corp  Advantages      Prosthodontics acceptability good Company will replace implants that fail Simple surgery Good education Moderate cost  Disadvantages  Suggests very low hand piece rpm (300 rpm, 70-1 reduction), can get higher rpm if desired
  76. 76. Stryker PrecisionStryker Inc  Advantages     Moderate cost Relatively simple surgery Hand auger ostectomy is kind biologically Mechanical retention good  Disadvantages     Fair prosthodontic acceptability Education availability fair Prosthodontic esthetics can be difficult because of some head designs Lacks ADA acceptance
  77. 77. To Conclude  The ultimate goal, the restoration of all lost teeth, gingiva and bone, is rarely achievable. The realistic goal is to restore a sufficient quantity and quality to meet the individual patient’s need. It is achieved when the prosthesis is integrated into patient mouth and patient becomes unaware of restoration. Dental implants are successful and some brands are well accepted and approved by major dental organizations. Implant Prosthodontics is a rapidly developing field.
  78. 78. References:  Ralf V McKinney Jr: Endosteal Dental Implants  Carl E Mish: Contemporary Implant Dentistry Ed 2nd.  Charles English. Journal Of American Dentisty Sept 1990;330-424.
  79. 79. Thank You Leader in continuing dental education