Indications & contra


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Indications & contra

  1. 1. Member A.O.I.AFellow I.C.O.IScientific consultant of sybron implant solutionsManager of implant direct company Dr. Amr Saad
  2. 2. Dr. Amr Saad
  3. 3. . Bad oral hygiene. Bad habits (clenching , nail biting …etc). Smoking. Diabetes. Osteoporosis. Hormonal disorders. Radiation therapy. Chemo therapy Dr. Amr Saad
  4. 4.  It is the evaluation of all circumstances that can affect the outcome of a therapeutic intervention. In the case of dental implants the assessment is to identify variables that increase the risk of complications leading to implant loss. Dr. Amr Saad
  5. 5.  Risk assessment should be performed: 1) Before placement of implants (designed to avoid high failure rates by identifying suitable candidates for implant treatment). 2) During the phase of implant placement and osseointegration (designed to identify and avoid technical issues that can affect implant survival). Dr. Amr Saad
  6. 6. 3) During the phase of implant maintenance (designed to minimize failure by heading off problems).4) After an implant has failed and been removed ( to identify the causes of failure ) . Dr. Amr Saad
  7. 7.  It is an environmental, behavioral, or biological factor. If present directly increases the probability of a disease occurring and, if absent or removed, reduces that probability. Dr. Amr Saad
  8. 8.  In the case of risk assessment for implant failure, risk factors can be broadly categorized as 1) Local risk factors. 2) Systemic risk factors. 3) Behavioral risk factors. Dr. Amr Saad
  9. 9. 1. Taking thorough medical/dental histories.2. Complete examination of the prospective candidate for dental implants. Dr. Amr Saad
  10. 10.  A comprehensive evaluation of the patient should contain a review of past dental history including: 1) Earlier periodontal treatment. 2) Reasons for tooth loss. 3) How extraction sockets were treated at the time of extraction. 4) History of increased susceptibility to infection. Dr. Amr Saad
  11. 11. 5) Awareness of parafunctional habits such as clenching and grinding. 6) Evaluation of the patient’s socioeconomic status. 7) Dissatisfaction with earlier dental treatment may indicate an increased risk for complications during implant therapy. The comprehensive medical history should include past and present medications and any substance abuse. Dr. Amr Saad
  12. 12.  A complete intraoral examination should be performed to determine the feasibility of placing implants in desired locations. This examination includes: 1. Oral hygiene status. 2. Periodontal status. 3. Jaw relationships. 4. Occlusion. 5. Signs of bruxism. 6. Temporomandibular joint conditions. Dr. Amr Saad
  13. 13. 7. Endodontic lesions.8. Status of existing restorations.9. Presence of non-restored caries.10. Crown-root ratio.11. Interocclusal space.12. Available space for implants.13. Ridge morphology.14. Soft and hard tissue conditions.15. Prosthetic restorability. Dr. Amr Saad
  14. 14.  Radiographic evaluation of the quality and quantity of available bone is required in order to determine the optimal site(s) for implant placement. Dr. Amr Saad
  15. 15. 1. Periapical radiographs.2. Panoramic projections.3. Cross-sectional tomographic images give accurate estimation of bone height and width. Dr. Amr Saad
  16. 16.  A comprehensive radiographic evaluation minimizes the risk of injuring vital anatomic structures during the surgical procedure and is also helpful in determining which cases require bone augmentation surgery before implants can be placed. Dr. Amr Saad
  17. 17.  An evaluation of the quality and quantity of peri-implant soft tissues at the proposed implant site will help determine how closely this tissue will mimic the appearance of gingival tissue once the implant has been inserted. Dr. Amr Saad
  18. 18.  The presence of keratinized mucosa around a dental implant is an important part of an esthetically successful dental implant. It is important to evaluate the patient’s perception of esthetics prior to implant placement especially in situations with compromised hard and soft tissues. Dr. Amr Saad
  19. 19.  Diagnostic casts and intraoral photographs can be helpful in evaluating potential esthetic outcomes as well as in the overall treatment- planning process. In general, to minimize the risk of implant complications and failure, any diseases of the soft or hard oral tissues should be treated before implant therapy. Dr. Amr Saad
  20. 20.  Poor oral hygiene and microbial biofilms are important etiologic factors leading to the development of peri-implant infections and implant loss. Dr. Amr Saad
  21. 21.  There are several reasons to believe that untreated or incompletely treated periodontitis increases the risk for implant failure. 1) There are case reports that suggest an association (Malmstrom et al. 1990, Fardal et al. 1999) Dr. Amr Saad
  22. 22. 2) A similar subgingival microbiota has been found in pockets around teeth and implants with similar probing depths.3) Evidence exists that periodontal pockets might serve as reservoirs of pathogens that hypothetically can be transmitted from teeth to implants. Dr. Amr Saad
  23. 23.  Subgingival sites are the natural or preferred habitat of a diverse group of oral microorganisms. In an interesting study of 15 patients, Devides and Franco (2006) sampled mucosa-associated biofilms of edentulous sites with paper points and analyzed the specimens using polymerase chain reaction (PCR) methods to detect certain periodontal pathogens. Dr. Amr Saad
  24. 24.  At the edentulous sites Aggregatibacter actinomycetemcomitans was detected in 13.3% of subjects, Prevotella intermedia was detected in 46.7% of subjects, and Prophyromonas gingivalis was not detected. Six months after placement of endosteal implants at the same sites, subgingival plaque samples taken from around the implants were positive for A. actinomycetemcomitans in 73.3% of subjects, Pr. Intermedia in 53.3% of subjects, and P. gingivatis in 53.3% of subjects. Dr. Amr Saad
  25. 25.  None of the implants showed any clinical signs of either failure or peri-implantitis. These results indicate that healthy subgingival sites around implants are readily colonized by periodontal pathogens without any development of clinically detectable disease. Dr. Amr Saad
  26. 26.  It is important to remember that the microbiota adjacent to failing implants will differ depending on the cause of the failure. For example, the microbiota associated with implants failing because of traumatic loads was different to that found around implants failing because of infection. Dr. Amr Saad
  27. 27.  There are several reports that the survival rate of implants is decreased when the patient has a history of periodontitis. Patients who have had periodontitis might also be more susceptible to peri-implant infections. Dr. Amr Saad
  28. 28.  Acute infections Chronic infections Dr. Amr Saad
  29. 29.  It is clear that implants can be quite successful when placed in patients who are in their eighth and ninth decades of life. Several reports indicate that there is not a statistically significant relationship between age of the patient and implant failure. Dr. Amr Saad
  30. 30.  A potential problem associated with the placement of dental implants in still-growing children and adolescents is the possibility of interfering with growth patterns of the jaws. Osseointegrated implants in growing jaws behave like ankylosed teeth in that they do not erupt and the surrounding alveolar housing remains underdeveloped. Dr. Amr Saad
  31. 31.  It is highly recommended that implants not be placed until craniofacial growth has almost complete. 14-15 years in females 17 years in males Dr. Amr Saad
  32. 32.  Cigarette smoking is often identified as a statistically significant risk factor for implant failure. The reasons that smokers are more susceptible to both periodontitis and peri- implantitis, but usually involve impairment of innate and adaptive immune responses and interference with wound healing. Dr. Amr Saad
  33. 33. Dr. Amr Saad
  34. 34.  Smoking is such a strong risk factor for implant failure that some clinicians highly recommend smoking-cessation protocols as part of the treatment plan for implant patients. Dr. Amr Saad
  35. 35.  Bisphosphonates are drugs used for the treatment of osteoporosis. These drugs are potent inhibitors of osteoclast activaty (apoptosis) , have a high affinity for hydroxyapatite and have a very long half-life. Dr. Amr Saad
  36. 36.  An uncommon complication associated with the use of bisphosphonates is the increased risk of developing osteonecrosis of the jaws (ONJ) after implant placement. In general, it is not recommended that implants be placed in patients who have been on the drug for more than 3 years. Dr. Amr Saad
  37. 37.  Gingival enlargement has been reported around dental implants in individuals taking either phenytoin or a calcium-channel antagonist. Dr. Amr Saad
  38. 38.  It has been reported that some cancer patients who had received cytotoxic antineoplastic drugs experienced infections around existing transmucosal or endosteal dental implants (Karr et al. 1992). Dr. Amr Saad
  39. 39.  Patients who are receiving cancer chemotherapy should have thorough periodontal and implant maintenance care to minimize the development of adverse events. Dr. Amr Saad
  40. 40.  Patients who have blood-coagulation disorders or are taking high doses of anticoagulants are at an elevated risk of post-operative bleeding problems after implant surgery. Dr. Amr Saad
  41. 41.  Corticosteroids can interfere with wound healing by blocking key inflammatory events needed for satisfactory repair. In addition, through their immunosuppressive effects on lymphocytes, they can increase the rate of post-operative infections. Dr. Amr Saad
  42. 42.  In the early years of the AIDS epidemic placement of dental implants was ill advised since affected patients developed major life- threatening oral infections. With the advent of effective HAART (highly active anti-retroviral therapy) regimens, most HIV-positive patients who take their medications live for many years without developing Amr Saad Dr. severe opportunistic infections.
  43. 43.  Low T-helper (CD4) cell counts (i.e.<200/L) do not appear to predict increased susceptibility to intraoral wound infections or elevated failure rates of dental implants (Achong et al. 2006). Although more studies are needed, it appears that it is safe to place dental implants if the patient’s HIV disease is under medical control. Dr. Amr Saad
  44. 44.  Patients who have received radiation to the head and neck as part of the treatment for malignancies are at an increased risk of developing osteoradionecrosis (ORN). Implant failure rates of up to 40% have been reported in patients who have had a history of radiation therapy. Dr. Amr Saad
  45. 45. Dr. Amr Saad
  46. 46.  It has been recommended that oral surgical procedures in patients at risk of ORN be performed in conjunction with hyperbaric oxygen (HBO) therapy. From the perspective of risk- assessment procedures for implant placement, patients who have a history of irradiation to the jaws should be considered at high risk or implant failure and HBO interventions will probably lower that risk. Dr. Amr Saad
  47. 47. Dr. Amr Saad
  48. 48. Dr. Amr Saad
  49. 49.  In the risk evaluation of diabetics it is important to establish the level of metabolic control over the last 90 days is a blood test for glycosylated hemoglobin (HbA1C). Normal values for a non diabetic or a diabetic under good metabolic control are HbA1C 6-6.5% Dr. Amr Saad
  50. 50.  Diabetics with HbA1C values of ≥8% are under poor control and have an elevated risk of encountering wound healing problems and infection if dental implants are placed. Dr. Amr Saad
  51. 51. Osteoporosis is a skeletal conditions characterized by low bone mineral. There are multiple case reports that conclude that osteoporosis alone is not a significant risk factor for implant failure (Dao et al. 1993; Freiberg 1994; Fujimoto et al.1996; Freiberg et al. 2001). Dr. Amr Saad
  52. 52. Implants placed in individuals withosteoporosis appear to successfully Osseointegrate and can be retained for years.However, in cases of secondaryosteoporosis there are often accompanyingillnesses or conditions that increase the riskof implant failure (e.g. poorly controlleddiabetes mellitus, corticosteroidmedications). Dr. Amr Saad
  53. 53.  Long-term success of dental implants requires that the patient is able to comply with the recommended post- insertion maintenance procedures required for long-term survival and success of implants. Dr. Amr Saad
  54. 54.  Since poor oral hygiene is a documented risk factor associated with failure of implants, it is critically important that patients understand this and are taught the skills necessary to perform plaque removal on a daily basis. Dr. Amr Saad
  55. 55.  In addition, since patient-performed oral hygiene does not adequately remove disrupt dental plaque biofilms at subgingival locations, periodic maintenance visits are needed. It is recommended that these visits be at 3- month intervals. The patient’s compliance with the recommended maintenance schedule is a major key to long-term success. Dr. Amr Saad
  56. 56.  Patients who have addictions to alcohol and drugs are usually poor candidates for dental implants. Since the success of implant therapy requires a considerable amount of patient cooperation at all stages of care, individuals with substance-abuse problems should receive prosthetic care that does not depend on implants. Dr. Amr Saad
  57. 57.  In general, Patients who have severe mental health problems or exhibit psychotic behavior are not good candidates for dental implants. The cooperation needed for successful implant therapy is missing. However, people with medically controlled mental health problems, such as depression, can be successfully treated with implants. Dr. Amr Saad
  58. 58.  It is important that the practitioner determine if the information they tried to convey was understood. One of the best ways to do this is to convey the information in easily understood (nontechnical) language and in small increments. Patients who understand what is being done are usually quite cooperative and this cooperation leads to the increased probability of successful therapeutic outcomes. Dr. Amr Saad
  59. 59.  Daily self-care (oral hygiene) and adherence to a maintenance-recall schedule is absolutely required for long- term success. This is best discussed to the patient at the consultation Saad Dr. Amr visit.
  60. 60.  An effective way to reduce the risk of implant complications and failure is to stress the importance of the patient’s role as and active participant in the overall therapeutic program. Long-term success of both periodontal and implant therapy depends on an effective partnership between the patient and practitioner. Dr. Amr Saad
  61. 61. ASA Classification of Physical StatusP1: Normal, healthy patientP2: Patient with mild systemic disease with no functionallimiltation,ie, a patient with a significant disease that is under good day today control,eg controlled hypertension, oral agents for DM, mild COPDP3: Patient with severe systemic disease with definite functionallimitations, ie, patient who is concerned with their healthproblems each day, eg. aDM on Insulin, significant COPDP4: patient with severe systemic disease that is constant threat tolifeP5: Moribund patient who is not expected to survive 24hrsP6: Declared brain dead Dr. Amr Saad
  62. 62.  Post-operative infections increase the risk of early implant failure. It is important to perform implant surgeries with a strict hygiene protocol to minimize bacterial contamination of the surgcial site. Dr. Amr Saad
  63. 63.  The incidence of post-operative infection associated with implant placement is only about 1% (Powell et al. 2005), some clinicians attempt to reduce this risk by prescribing pre-operative systemic antibiotics (Dent et al. 1997; Laskin et al. 2000). In addition, the results of several case-control studies indicate that there is no advantage in using antibiotics in conjunction with implant placement (Gynther et al. 1998; Morris et al. 2004; Powell et al. 2005). Dr. Amr Saad
  64. 64.  Thermal damage to bone can be caused during the drilling sequence if dull drills are used or if osteotomy is performed without using enough liquid coolant. Dr. Amr Saad
  65. 65.  Post-insertion stability lowers the risk of implant complications or failure. Dr. Amr Saad
  66. 66.  In situations where there are less than optimal bone conditions. (thin cortex, low trabecular density), increased initial stability have to be established Dr. Amr Saad
  67. 67.  Anatomic structures that are at risk of damage during the placement of implants include:  Nerves,  Blood vessels,  Floor of the mouth,  Nasal cavity, maxillary sinuses,  Adjacent teeth. Dr. Amr Saad
  68. 68. 1. A Key part of implant therapy is the risk- assessment process that includes thorough medical and dental histories, a complete clinical examination, and an appropriate radiographic survey.2. The presence of one risk factor alone is usually insufficient to cause the adverse outcome. It is the combination of multiple risk factors that the has clinical importance. Dr. Amr Saad
  69. 69. 3. To minimize the risk of implant complication clinicians can use a number of technical procedures, such as adhering to a strict hygienic surgical protocol, performing the osteotomies with sharp drills, achieving early implant stability, and avoiding damage to vital anatomic structures during surgery.4. Any endodontic, periodontal, and other oral infections be treated prior to implant placement. Dr. Amr Saad
  70. 70. 5. Existing evidence does not support the routine use of pre-operative systemic antibiotics in implant therapy.6. Most of the systemic risk factors for implant complications are those that increase the patient’s susceptibility to infections or those that interfere with wound healing. Dr. Amr Saad
  71. 71. Dr. Amr Saad