INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
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The Mayan civilisation  earliest
known examples of endosseous
implants dating back to 600 AD.
This mandible had 3 tooth-s...
 It was 1350 years later that professor Per-Ingvar Branemark
discovered the phenomenon of “Osseointegration”.
 In 1965 h...
SURGICAL ANATOMY
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1. Optimally plan and place dental implants.
2. Locate and determine the distance to vital anatomic structures
3. Measure ...
Maxilla
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Nasopalatine foramen & canal
 incisive foramen
Incisive canals/foramina of Stenson
4.6mm wide
~7.4mm from labial surfa...
Infra-orbital foramen
 ~ 5mm below infra – orbital ridge
 Care taken in case of severely resorbed ridges
during flap ele...
Greater Palatine Artery
 Foramen – opp 3rd molar
 Foramen – mid sagittal plane = 16mm
 Greater palatine artery – 12.7to...
Maxillary sinus
 Antrum of Highmore
 Typical dimensions  ht(36-45mm),width(25-
35mm), length (38-45mm)
Osteum to antra...
Mandible
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Arteria submentalis/ Vena facialis
 Bleeding
 Swelling
 At times may be life-threatening
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 Careful palpation  a concavity below the mylohyoid
ridge, as will tomographic views of this region.
 Implants placed i...
Mandibular Foramen
 Location – varies based on race and ethnicity
 2.5%-23.5% block injections given at the occlusal lev...
Inferior Alveolar Canal
 It houses the inferior alveolar nerve, artery, vein
and lymphatics.
 Canal  ~ 3.4mm wide, Nerv...
 Osteotomy over mandibular nerve  cortical bone
followed by cancellous bone
 IAC  surrounded by cortical bone
 Howeve...
 The variations in the course of IAC are frequent.
(Nortje´ et al.1977; Berberi et al. 1994; Anil et al. 2003)
 Liu et a...
TYPE 1
(Linear)
Smallest curvature
TYPE 4
(Turning Curve)
Largest variation
TYPE 3
(Elliptic Arc)
Most common
(48.5%)
TYPE...
The distance from the superior border of IAC to the alveolar crest (U5,U6,U7,U8)
The distance from inferior border of IAC ...
Mental Foramen and Nerve
3 nerve branches
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 Location  differs in horizontal and vertical plane
 Whites – b/w apices of pre molars
 Chinese – next to 2nd pre mola...
Anterior loop – IAN courses inferiorly and anteriorly and
then loops back to emerge from the foramen.
No Loop
Loop present...
 Loop dimensions – on radiographs (0-7.5mm), on cadaver
specimens (0-1mm), on panoramic radiographs (0.5-3.0mm)
 When th...
Mandibular Incisive Canal
 “True” incisive canal
 Reaches midline – only 18%
 Terminates apical to lateral or central i...
Lingual Foramen & Lateral Canals
 Lingual foramen – an artery
 Risk of haemorrhage in case of a large canal >
1mm
Submen...
Lingual & Mylohyoid Nerve
 Lingual nerve – 3mm apical to the crest & 2mm from the
lingual cortical plate in the flap
 Av...
MENTALIS
Witch’s chin – entire resection of the muscle
Incase of sharp vestibular desection – special suturing
MYLOHYOID M...
Zone of Safety
 An area within the bone that can safely
support implants without fear of
impingement on the mandibular
ne...
Nerve Relocation
Buccal repositioning of the inferior alveolar canal :
Removal of buccal cortical plate
Inferior alveola...
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History & Examination
 Medical Questionnaire…
 Physical Examination…
 Laboratory Evaluation
- Complete blood cell count...
 History of drug allergy…….. LA, Antibiotics etc.
 Use of any particular drug… ( Aspirin )
 Vital signs ( BP, Respirato...
DIAGNOSTIC METHODS
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1. Consider the position of the ridge crest
2. Conceptualise the height, width and length of the proposed
operative sites....
Manual Palpation
Boley’s gauge
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'Ridge mapping/Bone sounding’
Anesthetise the area
Sharpened probe  soft tissue thickness
Sterelised Boley’s guage  bone...
 Study Casts :
Diagnostic cast
Second (surgical )cast for surgical planning
Mounted using semi adjustable articulator
<7m...
DIAGNOSTIC IMAGING
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1. Radiography :
Intraoral Periapical radiograph
 Higher resolution
 Medullary and cortical bone density
Ball Bearing Te...
Extraoral radiographs
OPG : Presents an over all view of maxilla and mandible
Unpredictable distortion of distances(≥25%)
...
2. Computed Tomography : amount of bone available is
calculated to the millimeter.
3. MRI : secondary imaging technique
4....
 At the completion of the diagnostic measures,
the information available to the implantologist
will include :
alveolar ri...
Implant selection chart based on available bone
WIDTH RIDGE
DEPTH
LENGTH RECOMMENDED
IMPLANT TYPE
Available
bone
0-3mm 0-6...
Notes
 Narrow crestal bones can be flattened,available
depth must be re-assessed
 Distance b/w ridge crest and
1. Mandib...
 Root form implants (dia-3.25 to 6.3mm) & (length-
7to20mm). 1mm of additional bone required
 Spacing b/w root form impl...
PHASES PROCEDURES
I INTRODUCTION Elimination of a/c conditions
Extraction of hopeless teeth
Stabilisation of occlusion
II ...
Patient Consent
 Pt should be informed at the time of the initial visit about the
diagnosis, prognosis, the different pos...
Preparations for Surgery
 Armamentarium :
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 The Operatory :
 electrical delivery
system
 hand pieces
 burs and drills
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Sterilisation
 Universal precautions to prevent infections
includes :
protective attire and
barrier techniques
 Scrubbin...
•Patient should be asked to rinse his / her mouth with
0.2% Chlorhexidine mouthwash 10 min prior to the
surgery
•Para oral...
Principles of Surgery
- Incisions
- Flap design, retraction and
soft tissue management
- Bone management
- Sutures and sut...
Incisions
 Sharp scalpel – changed frequently.
 Incisions – crestal (if there is  3mm attached gingiva)
– vestibular
 ...
Flap design, Retraction
 Complete flap elevation without tearing the periosteum
 Flaps with releasing incisions should h...
Bone Management
 Maintain uninjured periosteal envelope
 Temperatures SHOULD NOT RISE BEYOND 47oC for
time as short as 3...
Density of Bone: Effect on Surgical Approach
Bone density classification :
D1 Mainly cortical plate compact bone
D2  Thi...
Usually Maxilla : anterior – D3
posterior – D4
Mandible : anterior – D2
posterior – D3
D1 bone – symphysis region
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Review of Literature
 Jaffin and Berman (1991) reported an overall 8.3%
surgical and initial healing loss in 444 maxillar...
Schematic drawings showing minimum
bone volume needed for standard implants
of the Branemark System.
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Schematic drawings indicating location of
minimum bone volume areas in distal
directions, and giving distances needed for
...
 Many published reports ….implant surgical failure of
3.2% to 5% in mandible and failure rates in maxilla
upto 1.9% to 2%...
3 factors to be considered after assessing bone quality
in order to achieve initial stability and osseointergration:
- The...
Soft bone  a narrow drill  more resistance to seating of the
implant More torque higher initial primary stability.
Mod...
BONE DRILLING
 The internally irrigated instrumentation
requires a specific technique to prevent the
irrigation holes fro...
 Caution: The drills are approximately 1 mm longer
than the implant being placed. Allow for this additional
length when d...
Implant position & direction
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Sutures and Suturing
 To approximate the incised tissue back together
 Complicated implant closure requires synthetic
re...
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 Two stage – Implant heals under the soft tissue
and is , after a healing period ,accessed through
a second stage surgery...
 Immediate implants – placement of implants into
fresh extraction sites.
 Early placement - implant placement 2-6 weeks
...
Two stage
One stage
Direct(flapless)
one stage surgery
Conventional or Delayed Implant Placement
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Initial preparation made using a surgical guide or template
to determine the implant location
 Surgical template :
Single...
 Free end saddle edentulous area :
four or more teeth should be included anterior
to the edentulous area
 Completely ede...
Two Stage
 Crestal incision
 Reflect the flap to directly observe the bone
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 Guide drill
 Twist drill
 Pilot drill
 3mm twist drill
 Countersink
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 Initial preparation :
 Round bur
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 Osteotomy is prepared
2mm end
cutting starter
linderman bur
2mm pilot
drills
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 Parallel indicators :
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Sequential drills 2.5,3,3.2
Side cutting crestal
bone drill
Bone tap
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 Threaded pre tap:
planned implant is inserted with a hand held ratchet
wrench or very low speed(5-10rpm) motor drive is ...
 Pilot drill is followed by series of end cutting drills, which gradually
increase the diameter of the osteotomy
 Counte...
Not to exceed 45 Ncm
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 Implant is inserted at or slightly below the crest of bone
 Slow speed high torque handpiece is usually used to
thread ...
 Site is rinsed
 Low profile cover screw (coated with antibiotic) is then
inserted
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 Tissue are then approximated over implant for
primary closure
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 Healing period is about 4-6 months and longer on D4
bone and Grafted areas.
 Technique requires a second stage surgery ...
Advantages of the two stage surgery
 Observation of crestal bone before osteotomy
 Observation during osteotomy preparat...
 one stage surgery uses a similar incision and reflection
technique to observe crestal bone
One stage surgery
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 At the conclusion of implant surgery Permucosal
healing abutment is placed into the implant .
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 Implant is also placed slightly above the crest of
the bone
 Soft tissue is then sutured around the PME
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Advantages one stage surgery
 Soft tissue matures while bone interface is healing
 Surgical appointment is reduced
 Hig...
 Modification of one stage surgery
 Doesn’t reflect the crestal soft tissue
Direct (flapless) one stage surgery
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 Core of keratinized tissue( size of the implant
crest modules diameter) is removed over the
crestal bone
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 Implant osteotomy is performed in the centre of
the core exposed bone
 Technique doesn’t require sutures
Advantages of ...
Disadvantages of flapless surgery
 Inability to assess the bone volume before or
during implant osteotomy or insertion
 ...
Factors to be considered when implant is
placed in esthetic zone
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 When an implant is placed in esthetic zone
 The site must be thoroughly evaluated
 Garber has proposed a classificatio...
 Vertical and horizontal level of both soft tissue and bone
Implant placement is a straight forward
 Thin gingival bioty...
 Normal vertical bone and slight horizontal bone deficiency
about 1 to 2 mm
 Expanded using serial osteotomes instead of...
 No vertical bone loss and horizontal bone loss
greater than class II
 Implant placement can be attempted
 Initial stab...
 No vertical bone loss but significant horizontal bone loss
 Staged approach is necessary
 Implant is placed after suit...
 Extensive apicocoronal bone loss

Garber class V
Non resorbable membrane and
delayed implant placement
Barrier membrane...
Principles of Implant Body Position
Vertical position
Implant
angulation
Labiopalatal
position
Mesiodistal
position
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Vertical Positioning
 Midcrestal positioning of the edentulous site
 2-3 mm below the facial CEJ of the adjacent teeth
w...
Mesiodistal Position
 Implant should be at least 1.5-2 mm from an
adjacent tooth and 3 mm to adjacent implants.
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Labiopalatal Positioning
 Should be 2mm greater than the implant diameter
 The crestal bone should be 1.5 mm on labial a...
Implant Angulation
Within the
cingulum
position of the
implant crown
Under the
incisal edge
of the final
restoration
Facia...
Facial implant body angulation
 An implant is in the position of natural root of the tooth
 It places the implant too fa...
Incisal edge of the final restoration
 Centre of the implant is located directly under the incisal
edge of the crown
 St...
Cingulum Implant body angulation
 Emerges under the cingulum of the crown
 Indicated for screw retained crown
 Facial p...
Immediate Implants
Indication
Retained deciduous teeth
Vertically and
horizontally fractured
teeth
Tooth loss due to carie...
Risk factor
for
immediate
implant
If overt infection
Poor bone
quality and
quantity
Presence of high
masticatory
Parafunct...
Certain Clinical Requirement for Immediate
Implants
Absence of active
infection
Preservation of labial plate
Use of approp...
Protocols
for implant
placement
in
extraction
socket
Type
I
Type
IV
Type
III
Type
II
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 Implant placement immediately following tooth extraction
Part of same surgical procedure
Advantages
 Reduced no of surg...
Disadvantages
 Site morphology
 Thin tissue biotype
 Lack of keratinized mucosa
 Technique sensitivity
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 Complete soft tissue coverage of the sockets (typically 4-
8 weeks)
Advantages
 Increased soft tissue area and volume
...
 Substantial clinical or radiographic bone fill of the
socket.(typically 12 – 16 weeks)
 Advantages
• Bone fill facilita...
 Healed site ( typically >16 weeks )
 Advantages
 Healed ridges
 Matured soft tissue
 Facilitates flap management
Typ...
Histology and clinical trials
 Most reports on immediate implants placement describe
small peri-implant osseous defects r...
 These small defects heal with bone fill
 Defect less than 2mm in width , no augmentation or
membrane is required
 Dehi...
Guideline for extraction when planning
for immediate implant placement
Preoperative evaluation
Antibiotic therapy initia...
Osteotomy preparation
Improvements of placement
 bone graft
Soft tissues closure
Successful osseointegration
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 Thoroughly evaluated
 Acute situation may not allow for preliminary evaluation
 Any sign of potential acute infection
...
 Use periotome for removal of teeth in atraumatic manner
Preservation of bony receptor site
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 If any purulent is discovered after removing the tooth
 placement of the implant should be delayed
 Affected area shou...
 Socket consists of thin, dense layer of cortical bone.
 During socket preparation care must be taken not to
create any ...
 In maxilla palatal wall is thicker than the buccal wall
 denser palatal bone will cause the drill to forced to the
labi...
 The best position of implant is under incisal edge
 This doesn’t coincide with root apex position
Osteotomy preparation...
 Once correct position is confirmed
 Standard drilling procedures are performed
2mm twist drills prepare the osteotomy t...
The osteotomy is kept in an angulation aligned with the
incisal edge of the adjacent teeth
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 incremental drills prepare to the final length and diameter
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 Bone tap is used to its final depth
 Implant is threaded into position using
slow speed, high torque handpiece.
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 Bone cell will damaged if temp is raised in the bone to 47
degree for more than 1 mins.
 Careful cooling with copious s...
 Implant should be seated two third in the host bone.
 The apex should be 1mm or 2mm longer than tooth being
replaced
 ...
 The gap between the osseous walls of the socket and the
implant fixtures is filled with the bone grafting materials
www....
 Complete soft tissue closure on top of implants might
present for the overall success of dental implants therapy
(Lekhol...
 Successful osseointegration can be increased
by a stress free nonfunctional healing period
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Improved
preservation of
the soft tissue
Bone
architecture
Bone
augmentation
and soft tissue
grafts may be
avoided
Reduced...
Better esthetic
Simplification of prosthetic
design
Improvement in patient
psychological
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Reduced vestibular
depth
Deep or shallow
implant placement into
the socket
Increased risk of
postoperative
infections
Bone...
Esthetic outcome of immediate implant
 bone resorption during the first six months post
extraction esthetic defect
 IMP ...
 Achieving esthetic success is suggested to be dependent
on ideal 3 dimensional implant position (Buser et al 2004)
 Mai...
Implant Surgeries for Various Types of
Implants
1. Endosteal implants :
root form
blades
ramus blade and frame
transosteal...
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Blade and Plate Form Implants
 Know the thickness and depth of the prospective host site
 If ridge is less than 3mm wide...
osteotomy
Perforations made 2mm apart
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Implant Placement
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Ramus Frame and Ramus Blade
Implants
 Anterior incision and osteotomy made first
 Anterior foot of the ramus frame bent…...
Anterior incision
Template bending Anterior osteotomy
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Posterior osteotomy
Seating of frame Closure of site
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Post operative panaromic radiograph
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Ramus Blade Implants
 Distal abutment for fixed
bridge in atrophic
mandible
 Used when as little as
4mm bone present
www...
Incision Implant in place
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Transosteal Implants
 Application is in overdentures
 Suitable in mandible anterior region ; complete or partial
edentul...
Skin incision Dissection exposing inferior border
Of mandible
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Osteotomy with
3/64inch diameter drill
Implant-firm frictional fit
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Intraoral closure
Self tapping screw positioned
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Subperiosteal Implants
 Complex impressions in several parts
 Tissue thickness measurements to be made ,to make a
castin...
Incision
Complete exposure of host bone
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Impression made by thermolabile
EZ tray material
Elastomeric impression made
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Vertical and centric relation record
Separated cast
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Vitallium casting of the
lateral ramus design
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radiograph of completed implant
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Second stage surgery
 Not required in non submerged systems
 Submerged implants are exposed
 After 3 months of first st...
Post operative guidelines
ROUTINE
 Antibiotics
 Analgesics
 Edema
 Local care : saline lavage hygiene
 Diet
 Postope...
 Apply ice to the surgical site for the next half
an hour intermittently..
 It is convenient to avoid hot food / liquids...
Recommended Diet Following
Implant Surgery
 For first 2 days: liquid diet like soups, high protien drinks
 Day 3 and 4 :...
Recall & Checkup
 Pt should be asked to visit after 2 days..
 Post surgical radiographs should be made to
evaluate the p...
Computer based treatment planning
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Complications
INTRAOPERATIVE COMPLICATIONS
 Hemorrhage
 Nerve injury
 Jaw fracture
 Opening of maxillary or nasal sinu...
POST OPERATIVE COMPLICATIONS
Immediate Delayed
Hemorrhage Peri implant
pathology
Hematoma Implant fracture
Edema Chronic s...
Summary and Conclusion
 Implant surgery is highly technique sensitive and
requires adequate training and an understanding...
Thank you
For more details please visit
www.indiandentalacademy.com
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Dental Implants surgical considerations / implant dentistry course/ implant dentistry course

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Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.

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  • Placement of implant too close will lead to interproximal bone loss and with subsequent papillary height .
  • Dental Implants surgical considerations / implant dentistry course/ implant dentistry course

    1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
    2. 2. The Mayan civilisation  earliest known examples of endosseous implants dating back to 600 AD. This mandible had 3 tooth-shaped pieces of shell placed into the sockets of three missing lower incisors. Compact bone formation around two of the implants was noted. www.indiandentalacademy.com
    3. 3.  It was 1350 years later that professor Per-Ingvar Branemark discovered the phenomenon of “Osseointegration”.  In 1965 he placed the first titanium dental implant into a human volunteer, a Swede named Gosta Larsson. www.indiandentalacademy.com
    4. 4. SURGICAL ANATOMY www.indiandentalacademy.com
    5. 5. 1. Optimally plan and place dental implants. 2. Locate and determine the distance to vital anatomic structures 3. Measure alveolar bone width and visualize bone contours 4. Determine if a bone graft or sinus lift is needed 5. Select the most suitable implant size and type 6. Optimize the implant location and angulation 7. Increased case acceptance 8. Reduced surgery time 9. Build patient confidence www.indiandentalacademy.com
    6. 6. Maxilla www.indiandentalacademy.com
    7. 7. Nasopalatine foramen & canal  incisive foramen Incisive canals/foramina of Stenson 4.6mm wide ~7.4mm from labial surface (unresorbed ridge Large canal – relocation(Artzi et al) enucleation (Rosenquist & Nystrom) Angulation of implant www.indiandentalacademy.com
    8. 8. Infra-orbital foramen  ~ 5mm below infra – orbital ridge  Care taken in case of severely resorbed ridges during flap elevation Infra-orbital Artery  Anastomose with PSA within buccal plate of bone  Lateral window preperation – hemorrhage  Apply pressure  CT scan- create lateral window inferior to it.  Use of piezosurgery www.indiandentalacademy.com
    9. 9. Greater Palatine Artery  Foramen – opp 3rd molar  Foramen – mid sagittal plane = 16mm  Greater palatine artery – 12.7to14.7mm from gingival margin  Incision – 2mm from the artery  Low vault – 7mm  Avg vault – 12mm  High vault – 17mm www.indiandentalacademy.com
    10. 10. Maxillary sinus  Antrum of Highmore  Typical dimensions  ht(36-45mm),width(25- 35mm), length (38-45mm) Osteum to antral floor  28.5mm. Hence, graft not to be filled beyond 15mm during sinus lift Septa – Underwood’s cleft. Get larger towards the medial. Hence membr elevation shoud proceed lateral to medial Schneiderian’s membr – 0.3-0.8mm thick. If thicker get ENT consultation prior to implant placement www.indiandentalacademy.com
    11. 11. Mandible www.indiandentalacademy.com
    12. 12. Arteria submentalis/ Vena facialis  Bleeding  Swelling  At times may be life-threatening www.indiandentalacademy.com
    13. 13.  Careful palpation  a concavity below the mylohyoid ridge, as will tomographic views of this region.  Implants placed in the posterior mandible are at risk of entering this region, which is highly vascularized, with resultant risks of haemorrhage. Mylohyoid ridge www.indiandentalacademy.com
    14. 14. Mandibular Foramen  Location – varies based on race and ethnicity  2.5%-23.5% block injections given at the occlusal level  ineffective  Inject 6-10mm above the occlusal plane  Needle length  short (21mm)  Patient symptomatic even after symptoms of good block  infiltrate lingual aspect of molar teeth (C2, C3) www.indiandentalacademy.com
    15. 15. Inferior Alveolar Canal  It houses the inferior alveolar nerve, artery, vein and lymphatics.  Canal  ~ 3.4mm wide, Nerve  ~ 2.2mm thick  The nerve (IAN) mainly contains sensory fibers. www.indiandentalacademy.com
    16. 16.  Osteotomy over mandibular nerve  cortical bone followed by cancellous bone  IAC  surrounded by cortical bone  However tactile feedback cannot be relied upon No substitutes for radiometrics, safety devices www.indiandentalacademy.com
    17. 17.  The variations in the course of IAC are frequent. (Nortje´ et al.1977; Berberi et al. 1994; Anil et al. 2003)  Liu et al (2009) OPG classification of the course of the nerve Linear Spoon shaped Elliptic arc Turning curve www.indiandentalacademy.com
    18. 18. TYPE 1 (Linear) Smallest curvature TYPE 4 (Turning Curve) Largest variation TYPE 3 (Elliptic Arc) Most common (48.5%) TYPE 2 (Spoon shaped) Largest curvature Highest bone height Most secure Relatively secure Greater risk Greater risk www.indiandentalacademy.com
    19. 19. The distance from the superior border of IAC to the alveolar crest (U5,U6,U7,U8) The distance from inferior border of IAC to the inferior border of mandible (D5,D6,D7,D8) www.indiandentalacademy.com
    20. 20. Mental Foramen and Nerve 3 nerve branches www.indiandentalacademy.com
    21. 21.  Location  differs in horizontal and vertical plane  Whites – b/w apices of pre molars  Chinese – next to 2nd pre molar  Atypically – near canine or 1st molar 1st premolar 2nd premolar Apical to apex 38.6% 24.5% At apex 15.4% 13.9% Coronal to apex 46.0% 61.6% www.indiandentalacademy.com
    22. 22. Anterior loop – IAN courses inferiorly and anteriorly and then loops back to emerge from the foramen. No Loop Loop present Loop Foramen www.indiandentalacademy.com
    23. 23.  Loop dimensions – on radiographs (0-7.5mm), on cadaver specimens (0-1mm), on panoramic radiographs (0.5-3.0mm)  When there is concern , the nerve should be exposed to identify its position  Chosen implant length  a safety margin of 2mm  Incase of an anterior implant longer than the safety distance – 6mm anterior to foramen www.indiandentalacademy.com
    24. 24. Mandibular Incisive Canal  “True” incisive canal  Reaches midline – only 18%  Terminates apical to lateral or central incisor  Width ~1.8mm  OPG – 15%, CT – 93%  Only large sized canals may pose a problem www.indiandentalacademy.com
    25. 25. Lingual Foramen & Lateral Canals  Lingual foramen – an artery  Risk of haemorrhage in case of a large canal > 1mm Submental & Sublingual Arteries  Dia ~2mm  Close to lingual plate  Submental or sublingual hematoma  swelling  airway obstruction www.indiandentalacademy.com
    26. 26. Lingual & Mylohyoid Nerve  Lingual nerve – 3mm apical to the crest & 2mm from the lingual cortical plate in the flap  Avoid lingual vertical incisions  Vertical incision distal to 2nd molar – buccal aspect  Mylohyoid nerve – may contribute to incomplete anesthesia in mandibular teeth  Long Buccal Nerve – Turner’s variation www.indiandentalacademy.com
    27. 27. MENTALIS Witch’s chin – entire resection of the muscle Incase of sharp vestibular desection – special suturing MYLOHYOID MUSCLE An important landmark seperating sublingual & submental spaces GENIOHYOID & GENIOGLOSSUS Inserted at genial tubercle Complete retraction  tongue falls back  airway obstruction DEPRESSOR ANGULI ORIS &LABII INFERIORIS Need reflection to expose mental foramen BUCCINATOR ORBICULARIS ORIS May need to be incised for coronal repositioning of flap MASSETER Released during harvesting of graft from ramus www.indiandentalacademy.com
    28. 28. Zone of Safety  An area within the bone that can safely support implants without fear of impingement on the mandibular neurovascular bundle.  Given by MISCH(1980)  Determined on OPG or clinically during surgery. www.indiandentalacademy.com
    29. 29. Nerve Relocation Buccal repositioning of the inferior alveolar canal : Removal of buccal cortical plate Inferior alveolar nerve is relocated from the canal Implant placement The nerve is brought back into roughly the same position Bone plate can be repositioned. In case of doubt the bone plate should not be repositioned to avoid any compression of the nerve www.indiandentalacademy.com
    30. 30. www.indiandentalacademy.com
    31. 31. History & Examination  Medical Questionnaire…  Physical Examination…  Laboratory Evaluation - Complete blood cell count - Bleeding Disorder tests  3 basic categories of information : - Past Medical History - Social & Family History - Review of patient’s Systemic Health www.indiandentalacademy.com
    32. 32.  History of drug allergy…….. LA, Antibiotics etc.  Use of any particular drug… ( Aspirin )  Vital signs ( BP, Respiratory Rate, Pulse, Temperature)  Complete Blood Cell count : - RBCs, WBCs, Leukocyte differential count, Hb% & Platelet count. www.indiandentalacademy.com
    33. 33. DIAGNOSTIC METHODS www.indiandentalacademy.com
    34. 34. 1. Consider the position of the ridge crest 2. Conceptualise the height, width and length of the proposed operative sites. 3. Determine the amount of well-keratinized masticatory mucosa. 4. Level of lip line, anu muscle attachments 5. Condition of remaining teeth and adjacent soft tissues Visual Examination www.indiandentalacademy.com
    35. 35. Manual Palpation Boley’s gauge www.indiandentalacademy.com
    36. 36. 'Ridge mapping/Bone sounding’ Anesthetise the area Sharpened probe  soft tissue thickness Sterelised Boley’s guage  bone width Done repeatedly from superior to inferior and medial to distal at 5mm intervals A topographic map of soft and hard tissue dimensions www.indiandentalacademy.com
    37. 37.  Study Casts : Diagnostic cast Second (surgical )cast for surgical planning Mounted using semi adjustable articulator <7mm in posterior region and <8 to 10mm in anterior region space, between potential implant site and opposing occlusal surface…. Additional space needs to be created. www.indiandentalacademy.com
    38. 38. DIAGNOSTIC IMAGING www.indiandentalacademy.com
    39. 39. 1. Radiography : Intraoral Periapical radiograph  Higher resolution  Medullary and cortical bone density Ball Bearing Templates can be seated intraorally prior to IOPA radiography.(5mm dia) rs/5 = rm/rx www.indiandentalacademy.com
    40. 40. Extraoral radiographs OPG : Presents an over all view of maxilla and mandible Unpredictable distortion of distances(≥25%) Lateral cephalographs : Helpful for completely edentulous patientscross-sectional morphology of residual ridges along with angles of inclination www.indiandentalacademy.com
    41. 41. 2. Computed Tomography : amount of bone available is calculated to the millimeter. 3. MRI : secondary imaging technique 4. CAD-CAM stereo tactic surgical templates : model of patient’s alveolar anatomy with osteotomy positions and orientations. www.indiandentalacademy.com
    42. 42.  At the completion of the diagnostic measures, the information available to the implantologist will include : alveolar ridge height, width, length, location of the nasal floor, antrum, foramina, interocclusal distances, periodontal status of remaining teeth and amount of healthy gingiva. www.indiandentalacademy.com
    43. 43. Implant selection chart based on available bone WIDTH RIDGE DEPTH LENGTH RECOMMENDED IMPLANT TYPE Available bone 0-3mm 0-6mm 0-7mm Sub-periosteal 3-5mm >8mm >10mm Blade >5mm >8mm 6-25mm Root form(1) >10mm 16-23mm Root form (2) 24-31mm Root form (3) >31mm Root form (1for each additional 7mm length) www.indiandentalacademy.com
    44. 44. Notes  Narrow crestal bones can be flattened,available depth must be re-assessed  Distance b/w ridge crest and 1. Mandibular canal 2. Antral floor 3. Nasal floor 4. Inferior border of mandible www.indiandentalacademy.com
    45. 45.  Root form implants (dia-3.25 to 6.3mm) & (length- 7to20mm). 1mm of additional bone required  Spacing b/w root form implants-equal the dia of one implant  Less dense bone-largest no of implants that the available space will permit, rough coatings will additionally help. www.indiandentalacademy.com
    46. 46. PHASES PROCEDURES I INTRODUCTION Elimination of a/c conditions Extraction of hopeless teeth Stabilisation of occlusion II PREPARATION Conservative periodontal therapy Initial endodontic therapy Pre-implant surgery Surgical template III SURGICAL Periodontal surgery in non-implant areas IV SURGICAL Implant surgery Periodontal surgery in implant areas V HEALING Maintenance procedures Crown preperation VI ABUTMENT FINALIZATION Uncovering of implants Use of healing caps and/or abutments Final preperation of teeth VII PROSTHODONTIC Impression Placement of prostheses Occlusal equilibration VIII MAINTENANCE Hygiene visits and home care www.indiandentalacademy.com
    47. 47. Patient Consent  Pt should be informed at the time of the initial visit about the diagnosis, prognosis, the different possible treatments with their expected results…  Possible chances of Damage to the nerve Paresthesia Rejection of implant Post-op pain or swelling www.indiandentalacademy.com
    48. 48. Preparations for Surgery  Armamentarium : www.indiandentalacademy.com
    49. 49.  The Operatory :  electrical delivery system  hand pieces  burs and drills www.indiandentalacademy.com
    50. 50. Sterilisation  Universal precautions to prevent infections includes : protective attire and barrier techniques  Scrubbing of hands www.indiandentalacademy.com
    51. 51. •Patient should be asked to rinse his / her mouth with 0.2% Chlorhexidine mouthwash 10 min prior to the surgery •Para oral structures should be disinfected using betadine prior to the surgery…… www.indiandentalacademy.com
    52. 52. Principles of Surgery - Incisions - Flap design, retraction and soft tissue management - Bone management - Sutures and suturing www.indiandentalacademy.com
    53. 53. Incisions  Sharp scalpel – changed frequently.  Incisions – crestal (if there is  3mm attached gingiva) – vestibular  If less than 3mm attached gingiva or the ridge is narrow a more facial approach is preferred.  May involve the sulcus of adjacent teeth. www.indiandentalacademy.com
    54. 54. Flap design, Retraction  Complete flap elevation without tearing the periosteum  Flaps with releasing incisions should have BROAD BASES  Gingivae of neighbouring teeth avoided whenever possible. www.indiandentalacademy.com
    55. 55. Bone Management  Maintain uninjured periosteal envelope  Temperatures SHOULD NOT RISE BEYOND 47oC for time as short as 30sec…therefore irrigation… www.indiandentalacademy.com
    56. 56. Density of Bone: Effect on Surgical Approach Bone density classification : D1 Mainly cortical plate compact bone D2  Thick compact bone with a dense trabecular core D3  Thin cortical plate with dense trabecular core D4  Thin cortical plate with low density trabecular core www.indiandentalacademy.com
    57. 57. Usually Maxilla : anterior – D3 posterior – D4 Mandible : anterior – D2 posterior – D3 D1 bone – symphysis region www.indiandentalacademy.com
    58. 58. Review of Literature  Jaffin and Berman (1991) reported an overall 8.3% surgical and initial healing loss in 444 maxillary implants with softer bone.  Hutton et al. (1995) identified poor bone quality and quantity of bone as the highest risk of implant failure in a study of 510 implants, with overall failure rate in maxilla being 9 times greater than in mandible. www.indiandentalacademy.com
    59. 59. Schematic drawings showing minimum bone volume needed for standard implants of the Branemark System. www.indiandentalacademy.com
    60. 60. Schematic drawings indicating location of minimum bone volume areas in distal directions, and giving distances needed for various numbers of implants. Arrows indicate prominence and apex of the nearest tooth. www.indiandentalacademy.com
    61. 61.  Many published reports ….implant surgical failure of 3.2% to 5% in mandible and failure rates in maxilla upto 1.9% to 2%.  Therefore consideration is given to methods to improve surgical survival of implants. www.indiandentalacademy.com
    62. 62. 3 factors to be considered after assessing bone quality in order to achieve initial stability and osseointergration: - The diameter of the implant - The diameter of the twist drill - The healing period www.indiandentalacademy.com
    63. 63. Soft bone  a narrow drill  more resistance to seating of the implant More torque higher initial primary stability. Moderately dense bone a slightly wider twist drillto make seating of the implant possible without too much torque. Dense bone  pre-tapping the bone site with a screw tap may be necessary to eliminate the need for forceful hand-wrench tightening. Extended healing time  soft bone sites. www.indiandentalacademy.com
    64. 64. BONE DRILLING  The internally irrigated instrumentation requires a specific technique to prevent the irrigation holes from becoming plugged with bone.  Drill in the bone for 1-2 seconds, and then move the drill up without stopping the handpiece motor to allow irrigation. www.indiandentalacademy.com
    65. 65.  Caution: The drills are approximately 1 mm longer than the implant being placed. Allow for this additional length when drilling near vital anatomic structures.  Recommended drill speed is 800 rpm.  Screwtap the bone at a maximum speed of 50 rpm. www.indiandentalacademy.com
    66. 66. Implant position & direction www.indiandentalacademy.com
    67. 67. www.indiandentalacademy.com
    68. 68. Sutures and Suturing  To approximate the incised tissue back together  Complicated implant closure requires synthetic resorbable material ..for long continous and complicated closures  Methods of closure : interrupted suture, continuous suture, vertical mattress suture.  CONTINUOUS BOX LOCK SUTURE www.indiandentalacademy.com
    69. 69. www.indiandentalacademy.com
    70. 70.  Two stage – Implant heals under the soft tissue and is , after a healing period ,accessed through a second stage surgery.  One stage - The implant heals without protection of the oral mucosa and is accessible through the mucosa during healing. Terminologies www.indiandentalacademy.com
    71. 71.  Immediate implants – placement of implants into fresh extraction sites.  Early placement - implant placement 2-6 weeks following tooth extraction www.indiandentalacademy.com
    72. 72. Two stage One stage Direct(flapless) one stage surgery Conventional or Delayed Implant Placement www.indiandentalacademy.com
    73. 73. Initial preparation made using a surgical guide or template to determine the implant location  Surgical template : Single tooth replacement : www.indiandentalacademy.com
    74. 74.  Free end saddle edentulous area : four or more teeth should be included anterior to the edentulous area  Completely edentulous area : www.indiandentalacademy.com
    75. 75. Two Stage  Crestal incision  Reflect the flap to directly observe the bone www.indiandentalacademy.com
    76. 76.  Guide drill  Twist drill  Pilot drill  3mm twist drill  Countersink www.indiandentalacademy.com
    77. 77.  Initial preparation :  Round bur www.indiandentalacademy.com
    78. 78.  Osteotomy is prepared 2mm end cutting starter linderman bur 2mm pilot drills www.indiandentalacademy.com
    79. 79.  Parallel indicators : www.indiandentalacademy.com
    80. 80. Sequential drills 2.5,3,3.2 Side cutting crestal bone drill Bone tap www.indiandentalacademy.com
    81. 81.  Threaded pre tap: planned implant is inserted with a hand held ratchet wrench or very low speed(5-10rpm) motor drive is used  Threaded self tap: firm downward pressure is exerted using a hand held ratchet  Non threaded press fits: no threading required tapped into slightly undersized osteotomies www.indiandentalacademy.com
    82. 82.  Pilot drill is followed by series of end cutting drills, which gradually increase the diameter of the osteotomy  Countersink drill is used when crest platform is at or below crest of bone.  Bone tap : Used in the crestal region of the osteotomy only… Performed at speed of less than 30rpm  NOTE : countersinking the implant may place it below the crestal cortical bone causing decreased stability during healing. www.indiandentalacademy.com
    83. 83. Not to exceed 45 Ncm www.indiandentalacademy.com
    84. 84.  Implant is inserted at or slightly below the crest of bone  Slow speed high torque handpiece is usually used to thread the implant into the bone at 30 rpm or less www.indiandentalacademy.com
    85. 85.  Site is rinsed  Low profile cover screw (coated with antibiotic) is then inserted www.indiandentalacademy.com
    86. 86.  Tissue are then approximated over implant for primary closure www.indiandentalacademy.com
    87. 87.  Healing period is about 4-6 months and longer on D4 bone and Grafted areas.  Technique requires a second stage surgery to uncover the implant body. www.indiandentalacademy.com
    88. 88. Advantages of the two stage surgery  Observation of crestal bone before osteotomy  Observation during osteotomy preparation  Ability to bone graft the site at the time of implant placement  Implant body healed at or below the crest of bone  Bacterial infiltration are not critical during healing www.indiandentalacademy.com
    89. 89.  one stage surgery uses a similar incision and reflection technique to observe crestal bone One stage surgery www.indiandentalacademy.com
    90. 90.  At the conclusion of implant surgery Permucosal healing abutment is placed into the implant . www.indiandentalacademy.com
    91. 91.  Implant is also placed slightly above the crest of the bone  Soft tissue is then sutured around the PME www.indiandentalacademy.com
    92. 92. Advantages one stage surgery  Soft tissue matures while bone interface is healing  Surgical appointment is reduced  Higher location of implant abutment connection may reduce some of the early crestal bone loss  Higher profile implant body also allows the prosthetic abutment with greater ease www.indiandentalacademy.com
    93. 93.  Modification of one stage surgery  Doesn’t reflect the crestal soft tissue Direct (flapless) one stage surgery www.indiandentalacademy.com
    94. 94.  Core of keratinized tissue( size of the implant crest modules diameter) is removed over the crestal bone www.indiandentalacademy.com
    95. 95.  Implant osteotomy is performed in the centre of the core exposed bone  Technique doesn’t require sutures Advantages of flapless surgery  Less soft tissue trauma coz tissue are not reflected www.indiandentalacademy.com
    96. 96. Disadvantages of flapless surgery  Inability to assess the bone volume before or during implant osteotomy or insertion  Only be used when the bone width is abundant  (>6-8mm) www.indiandentalacademy.com
    97. 97. Factors to be considered when implant is placed in esthetic zone www.indiandentalacademy.com
    98. 98.  When an implant is placed in esthetic zone  The site must be thoroughly evaluated  Garber has proposed a classification for such site www.indiandentalacademy.com
    99. 99.  Vertical and horizontal level of both soft tissue and bone Implant placement is a straight forward  Thin gingival biotype soft tissue augmentation Garber class I www.indiandentalacademy.com
    100. 100.  Normal vertical bone and slight horizontal bone deficiency about 1 to 2 mm  Expanded using serial osteotomes instead of drilling (Summers)  Slight expansion of bony ridge horizontally Garber class II www.indiandentalacademy.com
    101. 101.  No vertical bone loss and horizontal bone loss greater than class II  Implant placement can be attempted  Initial stability is achieved  GBR is necessary Garber class III www.indiandentalacademy.com
    102. 102.  No vertical bone loss but significant horizontal bone loss  Staged approach is necessary  Implant is placed after suitable healing period  Block bone graft or GBR technique Garber class IV www.indiandentalacademy.com
    103. 103.  Extensive apicocoronal bone loss  Garber class V Non resorbable membrane and delayed implant placement Barrier membrane with an immediately submerged implant as a space making under the membrane Distraction osteogenesis www.indiandentalacademy.com
    104. 104. Principles of Implant Body Position Vertical position Implant angulation Labiopalatal position Mesiodistal position www.indiandentalacademy.com
    105. 105. Vertical Positioning  Midcrestal positioning of the edentulous site  2-3 mm below the facial CEJ of the adjacent teeth www.indiandentalacademy.com
    106. 106. Mesiodistal Position  Implant should be at least 1.5-2 mm from an adjacent tooth and 3 mm to adjacent implants. www.indiandentalacademy.com
    107. 107. Labiopalatal Positioning  Should be 2mm greater than the implant diameter  The crestal bone should be 1.5 mm on labial aspect  0.5mm on palatal aspect . www.indiandentalacademy.com
    108. 108. Implant Angulation Within the cingulum position of the implant crown Under the incisal edge of the final restoration Facial implant body angulation www.indiandentalacademy.com
    109. 109. Facial implant body angulation  An implant is in the position of natural root of the tooth  It places the implant too facial and angled abutment is usually necessary. www.indiandentalacademy.com
    110. 110. Incisal edge of the final restoration  Centre of the implant is located directly under the incisal edge of the crown  Straight abutment for cement retention emerges directly below the incisal edge  Decreases the crestal stresses to the bone www.indiandentalacademy.com
    111. 111. Cingulum Implant body angulation  Emerges under the cingulum of the crown  Indicated for screw retained crown  Facial projection of the crown ,facing away from the implant body.  Facial ridge lab must extend 2 to 3mm. www.indiandentalacademy.com
    112. 112. Immediate Implants Indication Retained deciduous teeth Vertically and horizontally fractured teeth Tooth loss due to caries, endodontic failure Poor esthetics www.indiandentalacademy.com
    113. 113. Risk factor for immediate implant If overt infection Poor bone quality and quantity Presence of high masticatory Parafunctional habit www.indiandentalacademy.com
    114. 114. Certain Clinical Requirement for Immediate Implants Absence of active infection Preservation of labial plate Use of appropriate implant design Good mechanical anchorage Proper implant position www.indiandentalacademy.com
    115. 115. Protocols for implant placement in extraction socket Type I Type IV Type III Type II www.indiandentalacademy.com
    116. 116.  Implant placement immediately following tooth extraction Part of same surgical procedure Advantages  Reduced no of surgery  Reduced overall treatment time  Optimal availability of existing bone Type 1 www.indiandentalacademy.com
    117. 117. Disadvantages  Site morphology  Thin tissue biotype  Lack of keratinized mucosa  Technique sensitivity www.indiandentalacademy.com
    118. 118.  Complete soft tissue coverage of the sockets (typically 4- 8 weeks) Advantages  Increased soft tissue area and volume  Resolution of local pathology Type 2 Disadvantages  Varying amount of resorption  Increased treatment time  Adjunctive surgical procedure www.indiandentalacademy.com
    119. 119.  Substantial clinical or radiographic bone fill of the socket.(typically 12 – 16 weeks)  Advantages • Bone fill facilitates implant placement • Mature soft tissue facilitates flap management  Disadvantages • Same as type 2 Type 3 www.indiandentalacademy.com
    120. 120.  Healed site ( typically >16 weeks )  Advantages  Healed ridges  Matured soft tissue  Facilitates flap management Type 4 www.indiandentalacademy.com
    121. 121. Histology and clinical trials  Most reports on immediate implants placement describe small peri-implant osseous defects resulting in a gap.  Horizontal defect dimension or jumping distance (DCNA 2006 50 ) www.indiandentalacademy.com
    122. 122.  These small defects heal with bone fill  Defect less than 2mm in width , no augmentation or membrane is required  Dehiscence or fenestration defects required bone grafting and barrier membrane (DCNA 2006 50 ) www.indiandentalacademy.com
    123. 123. Guideline for extraction when planning for immediate implant placement Preoperative evaluation Antibiotic therapy initiation Preservation of bony receptor site Procedural delays Avoidance of excessive pressure www.indiandentalacademy.com
    124. 124. Osteotomy preparation Improvements of placement  bone graft Soft tissues closure Successful osseointegration www.indiandentalacademy.com
    125. 125.  Thoroughly evaluated  Acute situation may not allow for preliminary evaluation  Any sign of potential acute infection  Antibiotic therapy should be initiated before surgery Preoperative evaluation Antibiotic therapy initiation www.indiandentalacademy.com
    126. 126.  Use periotome for removal of teeth in atraumatic manner Preservation of bony receptor site www.indiandentalacademy.com
    127. 127. www.indiandentalacademy.com
    128. 128.  If any purulent is discovered after removing the tooth  placement of the implant should be delayed  Affected area should be irrigated and closed .  Tissue is then allowed to heal for several weeks until soft tissue closure is complete . Procedural delays www.indiandentalacademy.com
    129. 129.  Socket consists of thin, dense layer of cortical bone.  During socket preparation care must be taken not to create any force or pressure Avoidance of excessive pressure www.indiandentalacademy.com
    130. 130.  In maxilla palatal wall is thicker than the buccal wall  denser palatal bone will cause the drill to forced to the labial  Bone resorption ,leading to failure www.indiandentalacademy.com
    131. 131.  The best position of implant is under incisal edge  This doesn’t coincide with root apex position Osteotomy preparation www.indiandentalacademy.com
    132. 132.  Once correct position is confirmed  Standard drilling procedures are performed 2mm twist drills prepare the osteotomy to the opposing landmark side cutting drills www.indiandentalacademy.com
    133. 133. The osteotomy is kept in an angulation aligned with the incisal edge of the adjacent teeth www.indiandentalacademy.com
    134. 134.  incremental drills prepare to the final length and diameter www.indiandentalacademy.com
    135. 135.  Bone tap is used to its final depth  Implant is threaded into position using slow speed, high torque handpiece. www.indiandentalacademy.com
    136. 136.  Bone cell will damaged if temp is raised in the bone to 47 degree for more than 1 mins.  Careful cooling with copious sterile saline  Use of sharp drills  Control of the cutting speed www.indiandentalacademy.com
    137. 137.  Implant should be seated two third in the host bone.  The apex should be 1mm or 2mm longer than tooth being replaced  Implant diameter at the cervical area should be wide as possible to prevent soft tissue ingrowths.  Totally immobilized . Improvements of placement www.indiandentalacademy.com
    138. 138.  The gap between the osseous walls of the socket and the implant fixtures is filled with the bone grafting materials www.indiandentalacademy.com
    139. 139.  Complete soft tissue closure on top of implants might present for the overall success of dental implants therapy (Lekholm et al. 1993)  Protect bone grafting materials from the oral environment  Prevent the migration of epithelial tissue along the socket wall Soft tissues closure www.indiandentalacademy.com
    140. 140.  Successful osseointegration can be increased by a stress free nonfunctional healing period www.indiandentalacademy.com
    141. 141. Improved preservation of the soft tissue Bone architecture Bone augmentation and soft tissue grafts may be avoided Reduced surgical sessions Reduced cost Advantages www.indiandentalacademy.com
    142. 142. Better esthetic Simplification of prosthetic design Improvement in patient psychological www.indiandentalacademy.com
    143. 143. Reduced vestibular depth Deep or shallow implant placement into the socket Increased risk of postoperative infections Bone and implant contact reduced when facial plate resorbs Implant angulation problems DISADVANTAGES www.indiandentalacademy.com
    144. 144. Esthetic outcome of immediate implant  bone resorption during the first six months post extraction esthetic defect  IMP allows maintenance of gingival form  facilitates peri-implant gingival tissue esthetic { Douglass and Merin (2002)} www.indiandentalacademy.com
    145. 145.  Achieving esthetic success is suggested to be dependent on ideal 3 dimensional implant position (Buser et al 2004)  Maintenance of adequate buccal bone over the implant surface ( Grunder et al 2005) www.indiandentalacademy.com
    146. 146. Implant Surgeries for Various Types of Implants 1. Endosteal implants : root form blades ramus blade and frame transosteal 2. Sub periosteal implants 3. Intra mucosal inserts www.indiandentalacademy.com
    147. 147. www.indiandentalacademy.com
    148. 148. www.indiandentalacademy.com
    149. 149. Blade and Plate Form Implants  Know the thickness and depth of the prospective host site  If ridge is less than 3mm wide, flatten it … Incision Flap retraction www.indiandentalacademy.com
    150. 150. osteotomy Perforations made 2mm apart www.indiandentalacademy.com
    151. 151. Implant Placement www.indiandentalacademy.com
    152. 152. www.indiandentalacademy.com
    153. 153. Ramus Frame and Ramus Blade Implants  Anterior incision and osteotomy made first  Anterior foot of the ramus frame bent… www.indiandentalacademy.com
    154. 154. Anterior incision Template bending Anterior osteotomy www.indiandentalacademy.com
    155. 155. Posterior osteotomy Seating of frame Closure of site www.indiandentalacademy.com
    156. 156. Post operative panaromic radiograph www.indiandentalacademy.com
    157. 157. Ramus Blade Implants  Distal abutment for fixed bridge in atrophic mandible  Used when as little as 4mm bone present www.indiandentalacademy.com
    158. 158. Incision Implant in place www.indiandentalacademy.com
    159. 159. Transosteal Implants  Application is in overdentures  Suitable in mandible anterior region ; complete or partial edentulism www.indiandentalacademy.com
    160. 160. Skin incision Dissection exposing inferior border Of mandible www.indiandentalacademy.com
    161. 161. Osteotomy with 3/64inch diameter drill Implant-firm frictional fit www.indiandentalacademy.com
    162. 162. Intraoral closure Self tapping screw positioned www.indiandentalacademy.com
    163. 163. www.indiandentalacademy.com
    164. 164. Subperiosteal Implants  Complex impressions in several parts  Tissue thickness measurements to be made ,to make a casting with abutments that have accurate height  Lab must receive good surgical centric relation records www.indiandentalacademy.com
    165. 165. Incision Complete exposure of host bone www.indiandentalacademy.com
    166. 166. Impression made by thermolabile EZ tray material Elastomeric impression made www.indiandentalacademy.com
    167. 167. Vertical and centric relation record Separated cast www.indiandentalacademy.com
    168. 168. Vitallium casting of the lateral ramus design www.indiandentalacademy.com
    169. 169. radiograph of completed implant www.indiandentalacademy.com
    170. 170. Second stage surgery  Not required in non submerged systems  Submerged implants are exposed  After 3 months of first stage surgery  Healing abutment  Temporary prosthesis www.indiandentalacademy.com
    171. 171. Post operative guidelines ROUTINE  Antibiotics  Analgesics  Edema  Local care : saline lavage hygiene  Diet  Postoperative problems SPECIAL – ANTRAL SURGERY  Should give special instructions to patient www.indiandentalacademy.com
    172. 172.  Apply ice to the surgical site for the next half an hour intermittently..  It is convenient to avoid hot food / liquids during the first 24 hours.  Do not smoke.  Pt should be informed that pain & swelling can be seen… www.indiandentalacademy.com
    173. 173. Recommended Diet Following Implant Surgery  For first 2 days: liquid diet like soups, high protien drinks  Day 3 and 4 : pureed diet ,any food that blanderises well  Later : soft diet till day 14  Day 14 : return to normal diet www.indiandentalacademy.com
    174. 174. Recall & Checkup  Pt should be asked to visit after 2 days..  Post surgical radiographs should be made to evaluate the position of the implant..  Wound healing should be evaluated for uneventful healing… www.indiandentalacademy.com
    175. 175. Computer based treatment planning www.indiandentalacademy.com
    176. 176. Complications INTRAOPERATIVE COMPLICATIONS  Hemorrhage  Nerve injury  Jaw fracture  Opening of maxillary or nasal sinus  Consequences of improper implant placement - osseous dehiscence - osseous perforation - damage to adjacent teeth - insufficient primary stability www.indiandentalacademy.com
    177. 177. POST OPERATIVE COMPLICATIONS Immediate Delayed Hemorrhage Peri implant pathology Hematoma Implant fracture Edema Chronic sinusitis Early infection Chronic pain Wound margin separation Secondary nerve damage Mucosal perforations Mucosal irritation Implant mobility www.indiandentalacademy.com
    178. 178. Summary and Conclusion  Implant surgery is highly technique sensitive and requires adequate training and an understanding of the restorative requirements of the proposed treatment.  An understanding of the basic surgical principles is necessary to ensure successful osseointegration of the implant in the correct location which allows good esthetics and prognosis. www.indiandentalacademy.com
    179. 179. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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