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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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Dental Implants surgical considerations / implant dentistry course/ implant dentistry course

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education
  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.
  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.
  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
  6. 6. Maxilla
  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
  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
  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
  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
  11. 11. Mandible
  12. 12. Arteria submentalis/ Vena facialis  Bleeding  Swelling  At times may be life-threatening
  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
  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)
  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.
  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
  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
  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
  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)
  20. 20. Mental Foramen and Nerve 3 nerve branches
  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%
  22. 22. Anterior loop – IAN courses inferiorly and anteriorly and then loops back to emerge from the foramen. No Loop Loop present Loop Foramen
  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
  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
  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
  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
  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
  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.
  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
  30. 30.
  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
  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.
  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
  35. 35. Manual Palpation Boley’s gauge
  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
  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.
  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
  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
  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.
  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.
  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)
  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
  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.
  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
  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
  48. 48. Preparations for Surgery  Armamentarium :
  49. 49.  The Operatory :  electrical delivery system  hand pieces  burs and drills
  50. 50. Sterilisation  Universal precautions to prevent infections includes : protective attire and barrier techniques  Scrubbing of hands
  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……
  52. 52. Principles of Surgery - Incisions - Flap design, retraction and soft tissue management - Bone management - Sutures and suturing
  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.
  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.
  55. 55. Bone Management  Maintain uninjured periosteal envelope  Temperatures SHOULD NOT RISE BEYOND 47oC for time as short as 30sec…therefore irrigation…
  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
  57. 57. Usually Maxilla : anterior – D3 posterior – D4 Mandible : anterior – D2 posterior – D3 D1 bone – symphysis region
  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.
  59. 59. Schematic drawings showing minimum bone volume needed for standard implants of the Branemark System.
  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.
  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.
  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
  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.
  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.
  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.
  66. 66. Implant position & direction
  67. 67.
  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
  69. 69.
  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
  71. 71.  Immediate implants – placement of implants into fresh extraction sites.  Early placement - implant placement 2-6 weeks following tooth extraction
  72. 72. Two stage One stage Direct(flapless) one stage surgery Conventional or Delayed Implant Placement
  73. 73. Initial preparation made using a surgical guide or template to determine the implant location  Surgical template : Single tooth replacement :
  74. 74.  Free end saddle edentulous area : four or more teeth should be included anterior to the edentulous area  Completely edentulous area :
  75. 75. Two Stage  Crestal incision  Reflect the flap to directly observe the bone
  76. 76.  Guide drill  Twist drill  Pilot drill  3mm twist drill  Countersink
  77. 77.  Initial preparation :  Round bur
  78. 78.  Osteotomy is prepared 2mm end cutting starter linderman bur 2mm pilot drills
  79. 79.  Parallel indicators :
  80. 80. Sequential drills 2.5,3,3.2 Side cutting crestal bone drill Bone tap
  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
  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.
  83. 83. Not to exceed 45 Ncm
  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
  85. 85.  Site is rinsed  Low profile cover screw (coated with antibiotic) is then inserted
  86. 86.  Tissue are then approximated over implant for primary closure
  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.
  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
  89. 89.  one stage surgery uses a similar incision and reflection technique to observe crestal bone One stage surgery
  90. 90.  At the conclusion of implant surgery Permucosal healing abutment is placed into the implant .
  91. 91.  Implant is also placed slightly above the crest of the bone  Soft tissue is then sutured around the PME
  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
  93. 93.  Modification of one stage surgery  Doesn’t reflect the crestal soft tissue Direct (flapless) one stage surgery
  94. 94.  Core of keratinized tissue( size of the implant crest modules diameter) is removed over the crestal bone
  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
  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)
  97. 97. Factors to be considered when implant is placed in esthetic zone
  98. 98.  When an implant is placed in esthetic zone  The site must be thoroughly evaluated  Garber has proposed a classification for such site
  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
  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
  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
  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
  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
  104. 104. Principles of Implant Body Position Vertical position Implant angulation Labiopalatal position Mesiodistal position
  105. 105. Vertical Positioning  Midcrestal positioning of the edentulous site  2-3 mm below the facial CEJ of the adjacent teeth
  106. 106. Mesiodistal Position  Implant should be at least 1.5-2 mm from an adjacent tooth and 3 mm to adjacent implants.
  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 .
  108. 108. Implant Angulation Within the cingulum position of the implant crown Under the incisal edge of the final restoration Facial implant body angulation
  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.
  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
  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.
  112. 112. Immediate Implants Indication Retained deciduous teeth Vertically and horizontally fractured teeth Tooth loss due to caries, endodontic failure Poor esthetics
  113. 113. Risk factor for immediate implant If overt infection Poor bone quality and quantity Presence of high masticatory Parafunctional habit
  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
  115. 115. Protocols for implant placement in extraction socket Type I Type IV Type III Type II
  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
  117. 117. Disadvantages  Site morphology  Thin tissue biotype  Lack of keratinized mucosa  Technique sensitivity
  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
  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
  120. 120.  Healed site ( typically >16 weeks )  Advantages  Healed ridges  Matured soft tissue  Facilitates flap management Type 4
  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 )
  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 )
  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
  124. 124. Osteotomy preparation Improvements of placement  bone graft Soft tissues closure Successful osseointegration
  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
  126. 126.  Use periotome for removal of teeth in atraumatic manner Preservation of bony receptor site
  127. 127.
  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
  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
  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
  131. 131.  The best position of implant is under incisal edge  This doesn’t coincide with root apex position Osteotomy preparation
  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
  133. 133. The osteotomy is kept in an angulation aligned with the incisal edge of the adjacent teeth
  134. 134.  incremental drills prepare to the final length and diameter
  135. 135.  Bone tap is used to its final depth  Implant is threaded into position using slow speed, high torque handpiece.
  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
  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
  138. 138.  The gap between the osseous walls of the socket and the implant fixtures is filled with the bone grafting materials
  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
  140. 140.  Successful osseointegration can be increased by a stress free nonfunctional healing period
  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
  142. 142. Better esthetic Simplification of prosthetic design Improvement in patient psychological
  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
  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)}
  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)
  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
  147. 147.
  148. 148.
  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
  150. 150. osteotomy Perforations made 2mm apart
  151. 151. Implant Placement
  152. 152.
  153. 153. Ramus Frame and Ramus Blade Implants  Anterior incision and osteotomy made first  Anterior foot of the ramus frame bent…
  154. 154. Anterior incision Template bending Anterior osteotomy
  155. 155. Posterior osteotomy Seating of frame Closure of site
  156. 156. Post operative panaromic radiograph
  157. 157. Ramus Blade Implants  Distal abutment for fixed bridge in atrophic mandible  Used when as little as 4mm bone present
  158. 158. Incision Implant in place
  159. 159. Transosteal Implants  Application is in overdentures  Suitable in mandible anterior region ; complete or partial edentulism
  160. 160. Skin incision Dissection exposing inferior border Of mandible
  161. 161. Osteotomy with 3/64inch diameter drill Implant-firm frictional fit
  162. 162. Intraoral closure Self tapping screw positioned
  163. 163.
  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
  165. 165. Incision Complete exposure of host bone
  166. 166. Impression made by thermolabile EZ tray material Elastomeric impression made
  167. 167. Vertical and centric relation record Separated cast
  168. 168. Vitallium casting of the lateral ramus design
  169. 169. radiograph of completed implant
  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
  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
  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…
  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
  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…
  175. 175. Computer based treatment planning
  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
  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
  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.
  179. 179. Thank you For more details please visit