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implantology

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IMPLANTOLOGY 
 Dr V.RAMKUMAR 
 CONSULTANT DENTAL&FACIOMAXILLARY 
SURGEON 
 REG NO: 4118-TAMILNADU-INDIA(ASIA)

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What is implant? 
A dental implant is an artificial root that replaces 
the natural tooth root. 
Crown 
Gum 
Implant 
Toot...

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Parts of implant 
Cover screw 
Implant abutment interface 
Implant collar 
Fixture

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implantology

  1. 1. IMPLANTOLOGY  Dr V.RAMKUMAR  CONSULTANT DENTAL&FACIOMAXILLARY SURGEON  REG NO: 4118-TAMILNADU-INDIA(ASIA)
  2. 2. What is implant? A dental implant is an artificial root that replaces the natural tooth root. Crown Gum Implant Tooth Root Jawbone
  3. 3. Parts of implant Cover screw Implant abutment interface Implant collar Fixture
  4. 4. Tooth loss leads to bone loss - Anterior The more teeth that are lost, the greater the impact to your patient’s appearance and psychological well-being. Why Dental Implants?
  5. 5. Why Dental Implants? Tooth loss leads to bone loss - Posterior The average reduction in ridge height in the mandible during the first year after extraction is 4mm to 5mm. Note: Wear from clasp on an otherwise healthy adjacent tooth
  6. 6. CLINICAL OPTIONS preserve those two healthy teeth... Place a single implant and provide a restoration that looks, feels and functions like a natural tooth
  7. 7. Single-Tooth Implant: Advantages  High success rates (better than 97% for 10 years).  Decreased risk of caries of adjacent teeth.  Decreased risk of endodontic problems on adjacent teeth.  Improved hygiene.  Decreased cold or contact sensitivity of adjacent teeth.  Psychological advantage.  Decreased abutment tooth loss.
  8. 8. Consequences of Bone Loss in Fully Edentulous Patient  Decreased height & width of supporting bone.  Prominent mylohyoid and internal oblique ridges. With increased sore spots.  Progressive decrease in keratinized mucosa surface.  Prominent superior genial tubercles, sore spots, and increased denture movement.  Muscle attachment near crest of ridge.  Elevation of prosthesis with contraction of mylohyoid and buccinator muscles serving as posterior support.  Thinning of mucosa, with sensitivity to abrasion.
  9. 9. Contd..  Forward movement of prosthesis from anatomical inclination (angulation of mandible with moderate to advanced bone lass).  Loss of basal bone.  Paresthesia from dehiscent mandibular neurovascular canal.  More active role of tongue in mastication.  Effect of bone loss on esthetic appearance of lower one third of face.  Increased risk of mandibular body fracture from advanced bone loss.  Increased denture movement and sore spots during function caused by loss of anterior ridge and nasal spine.
  10. 10. Soft Tissue Consequences of Edentulism  Attached, keratinized gingiva is lost as bone is lost.  Unattached mucosa for denture support causes increased soft spots.  Thickness of tissue decreases with age, and systemic disease causes more sore spots for dentures.  Tongue increases in size, which decreases denture stability.  Tongue is more active in mastication, which decreases denture stability.  Neuromuscular control of jaw decreases in the elderly.
  11. 11. Esthetic Consequences of Bone Loss  Decreased facial height.  Loss of labiomental angle.  Deepening of vertical lines in lip and face  Rotation of chin forward, giving a prognathic appearance.  Decreased horizontal labial angle of lip, making patient look unhappy.  Loss of tone on muscles of facial expression.  Thinning of vermillion border of the lips from less of muscle tone.  Deepening of nasolabial groove.  Increase in columella-philtrum angle  Increased length of maxillary lip so that fewer teeth show at rest and smiling, which ages the smile.
  12. 12. Decreased Performance of Removable Prostheses  Bite force decreased from 200 psi to 50 psi.  Bite forces of 15-year denture wearers reduced to 6 psi.  Masticatory efficiency decreased.  Increased drug use for gastrointestinal disorders.  Possible decrease in life span.
  13. 13. Consequences of Removable Partial Dentures  Survival rate 60% at 4 years.  Survival rate 35% at 10 years.  Repair of abutment teeth.  Increased mobility, plaque, bleeding on probing, and caries of abutment teeth.  Abutment tooth loss of 44% within 10 years.  Accelerated bone loss in edentulous region if one wears a removable partial denture.
  14. 14. Psychological Effects of Tooth Loss  Psychological effects range from minimal to neuroticism.  88% of patients claim some difficulty with speech, and 25% have significant problems.
  15. 15. Advantages of Implant-supported Prostheses  Bone maintenance.  Restoration and maintenance of Occlusal vertical dimension.  Maintenance of facial esthetics (muscle tone).  Esthetic improvement (teeth positioned for appearance versus decreasing denture movement).  Improved phonetics.  Improved occlusion.  Improvement or allowance for regaining of oral proprioception (Occlusal awareness).  Increased prosthesis success.
  16. 16. Contd..  Improved masticatory performances and maintenance of muscles of mastication and facial expression.  Reduced size of prostheses (eliminate palate and flanges).  Provision for fixed versus removable prostheses.  Improved stability and retention of removable prostheses.  Elimination of need to alter adjacent teeth.  More permanent replacement.  Improved psychological health.
  17. 17. Dental implants preserve bone and … …healthy vital tooth structure. Implants are the conservative option.
  18. 18. 1. Endosseous or root-form Implants  Screw or Thread type Implants  Cylindric or Press fit type Implants  Tapered Implants 2. Blade form Implants 3. Subperiosteal Implants 4. Transosseous Implants  Mandibular staple Implant  Transmandibulor Implants or Bosker Implant
  19. 19. Blade form Implants Blade Implants are rectangular and are similar in shape to a razor-blade. The rectangular part of the Implant is placed into the bone via a Linear Osteotomy and the posts extend above the gingiva.
  20. 20. Subperiosteal Implants  These are metallic meshes that are custom-built to fit over the alveolar process and under the periosteum.  Several metal posts extend from the mesh into the oral cavity above the gingiva to support the prosthesis.
  21. 21. Cont.. This procedure involves two surgical visits:  In the first visit, the alveolar process is surgically exposed and an impression is obtained to fabricate the implant.  Implant is fabricated in the laboratory,  In the second visit, placement of the implant is done.
  22. 22. Transosseous Implants 1…Mandibular staple Implant: implant was indicated for patient with moderately resorbed mandibles but with at least 9 mm of vertical bone height present between the mental foramina.
  23. 23. 2…Transmandibulor Implants or Bosker Implant: This form of implant allows construction of a functional prosthesis without augmenting the mandibular body with bone and without stimulating further resorption or injury to the nerve.
  24. 24. Indications for TMI system  Severe mandibular atrophy.  Type IV bone quality.  Osteoporosis.  Factures of an atrophic mandible.  Parafunctional habits.  Following radiation therapy.  Mandibular resection and reconstruction.  Removal of endosseous, subperiosteal and transosseous Implants.
  25. 25. Endosseous or root-form Implants 1. Screw or Thread type Implants:  Uses threads for primary stabilization.  For the placement of the Threaded Implant the osteotomy site is tapped or prethreaded with a thread-former bur, to create the threads in the wall of the osteotomy site.
  26. 26. 2. Cylindric or Press fit type Implants:  Uses friction for primary stabilization.  The placement of a Cylindric Implant depends on the friction between the Implant surface and the bone. Thus no tapping is required.
  27. 27. 3. Tapered Implants:  Resemble a tooth root.  design for both Threaded and Press fit type Implant.  Initially design for immediate placement into extraction socket.
  28. 28. PPrree--SSuurrggiiccaall PPllaannnniinngg  Organized pre-surgical team planning is key to the success of an implant restoration. important considerations:  Implant placement  Occlusal design  Hygiene maintenance need to be discussed.
  29. 29. Medical Contraindications Absolute Contraindications  Recent myocardial infarction  Valvular prosthesis  Severe renal disorder  Uncontrolled diabetes  Uncontrolled hypertension  Generalized osteoporosis  Chronic severe alcoholism  Radiotherapy in progress  Heavy smoking(20 cig. a day)
  30. 30. RELATIVE CONTRA INDICATIONS  Cardiovascular problems  Congestive heart failure  Coronary artery disease  Prosthetic heart valves  Rheumatic heart disease  Endocrine disorders (e.g., calcium, iron, avitaminosis, low estrogen in females)  Hyperactive involuntary muscle movements (e.g., Parkinson’s, Huntington’s)  Bone disorders (e.g., osteomyelitis, osteopetrosis, osteoporosis)  Benign/malignant bone neoplasms or cysts and fibro-osseous disease  pregnancy
  31. 31. 3…Precautions should also be used in patients with histories of:  Blood dyscrasia (e.g.; anemia, sickle cell, polycythemia vera and purpura, granulocytopenia)  Pulmonary problems (e.g., asthma, bronchitis, emphysema)  Mental therapy  Psychiatric or psychological disorders  Mental retardation  Chemotherapy  Irradiation (5,000 rads or greater)  Hemophilia
  32. 32. Oral Contraindications:  Ridge dimensions are insufficient to accommodate proper implant placement  Lateral oral interferences are present  Habits such as-  Tobacco use  Alcohol consumption  Poor orel hygiene  Bruxism  Nail biting  Pencil biting  Tongue habits
  33. 33. Before Placement Of an Implant  Survey the surgical site clinically and radiographically to evaluate 1. Any residual infection is present in the bone 2. Presence of a periapical lesion in adjacent teeth
  34. 34.  Any active endodontic lesions adjacent to the implant site should be treated before endosseous implant placement.
  35. 35.  Any active endodontic lesions adjacent to the implant site should be treated before endosseous implant placement. Overhanging restoration / localized periodontal diseases periostits
  36. 36. PPaattiieenntt sseelleeccttiioonn Presentation of Patient:  Mental Status (alertness, coherence, comprehension)  Gait (manner, abnormalities)  Overall appearance (neatness, cleanliness)  Sign of tobacco and alcohol abuse
  37. 37. Patient’s Attitudes:  Chief complaints  Concept of own dental function and appearance  Expectations  Desired results  Oral hygiene  Esthetic expectations  Desired functional results
  38. 38. Patient’s dental history:  Condition of soft tissue  Condition of teeth  Edentulous areas  Current prosthesis and ability to provide esthetics, phonetis, and function  Temporomandibular joint problems
  39. 39. Proper blood screening and laboratory evaluation  Platelet count  PTT  PT  urinalysis
  40. 40. Diagnostic aids  Panoramic Radiographs  Lateral Cephalograms  Tomograms and CT scans  Mounted Study Cast and Diagnostic Wax-up
  41. 41. Surgical guide/Template The most important aim of a surgical guide is to guide the surgeon where to place the implant optimally. In addition, the surgical guide provides information about the tooth and supporting structures that have been lost. A well-designed surgical guide provides visual communication between the restorative dentist, implant surgeon and dental laboratory technician.
  42. 42. Implant Selection
  43. 43. Influence of implant diameter and length on crestal stress distribution  1). Greater the diameter of the dental implant less the crestal bone stress.  2). Greater the length of the implant less the crestal bone stress.
  44. 44. Implant Placement Procedure 4 Screw Tap 5 Implant placement 2 Tapered Drill ø 3.5 mm 3 Tapered Drill ø 4.3 mm 1 Twist Drill ø 2.0 mm
  45. 45. •Make an incision for elevation of a flap •Drill to the appropriate depth •Check orientation of the preparation site using direction indicator
  46. 46. • Drill to the desired depth to enlarge the implant site •Check orientation of the prepared site using direction indicator
  47. 47. • Drill to the desired depth to enlarge the implant site • Implant placement with implant driver Select RP
  48. 48. • Use the Surgical Torque Wrench to rotate the implant • Use the screwdriver to pick up the Cover screw and thread it into the implant • Close and suture the tissue flap
  49. 49. Direct sinus lift
  50. 50. Complications  Membrane perforation.  Presence of bony septae which divide sinus into separate compartments.  Postoperative infection.  Wound dehiscence.  Barrier Membrane exposure.  Transient sinusitis.
  51. 51.  The word osseointegration was defined as “a direct structural and functional connection between ordered, living bone and the surface of a load carrying implant.”  Bone healing around implants results in a well-defined progression of tissue responses that are designed to remove tissue debris, to reestablish vascular supply and produce a new skeletal matrix.
  52. 52. Prosthetic phase
  53. 53. Abutments Abutments are simply transmucosal extensions for the attachment of prostheses. Abutments can be used to provide a restorative connection above soft tissues and to provide for the biologic width. Abutments can be used for attachment of screw-retained or cemented connections and can be made of metal or ceramic. The most commonly used abutment material is machined titanium, which has been shown to be strong and resistant to plaque retention, and to react favorably to soft tissues.
  54. 54. Healing abutment/Gingival former
  55. 55. Esthetic abutment
  56. 56. Angled Esthetic Abutment
  57. 57. Multiunit abutment
  58. 58. Ball abutment
  59. 59. Bar supported over denture
  60. 60. Restorative solutions are the Goal With the internal connection, three broad categories of restorations are possible:  Cement-retained restorations  Screw-retained restorations  Overdenture restoration
  61. 61. Treatment Alternative  One-stage Immediate Function:  One-stage Delayed Function  Two-stage Delayed Function
  62. 62. One-stage Immediate Function Procedure overview restoring teeth with the implants and Immediate Function is similar to crown & bridge. Requirements for Immediate Function  High initial implant stability  Controlled loads  Osseoconductive implant surfaces
  63. 63. One-stage Delayed Function The one-stage surgical procedure does not require a second surgical stage, abutments are left protruding through the soft tissue.
  64. 64. Two-stage Delayed Function The two-stage surgical procedure protects dental implants from functional loading by submerging the implants below the mucosa at the time of placement. This requires a second surgical stage to uncover the implant.
  65. 65. 1 Abutment connection 2 Impression abutment level 3 Laboratory procedures 4 Final restoration
  66. 66. Maintenance phase  The importance of the maintenance procedures should never be underestimated by either the patient or the therapist.
  67. 67. Implant Hygiene Products  Soft bristle toothbrush  Non-abrasive toothpaste  Proxy brush  Dental floss  Electric toothbrushes  End-tuft brush  Antimicrobial rinses  Plastic scalers
  68. 68. Implant Hygiene Products
  69. 69. WWhhyy tthhee iimmppllaannttss ffaaiill…….. ??
  70. 70. CCllaassssiiffiiccaattiioonn  Surgical Complications: Inoperative Complications 1….Oversize Osteotomy. 2….Perforation of cortical plates. 3….Inadequate soft tissue flaps for Implant coverage. 4….Broken burs. 5….Improper Instrumentation 6….Hemorrhage. 7….Poor angulations & Position of Implant.
  71. 71.  PROSTHETIC COMPLICATIONS: Component & framework breakage 1….Fractured Frameworks & Mesostructure bars 2….Partial loosening of cemented bars and prostheses 3….Inaccurate fit of castings 4….Inadequate Torque application 5….In accurate frame work abutment interface 6….Occlusal factors 7….Implant Fracture 8….Implant loss
  72. 72.  Short term complications: ( 1… Postoperative infection. 2… Dysesthesia. 3… Dehiscent Implants. 4… Radiolucencies. 5… Antral complications. 6… Implant mobility.
  73. 73.  LONG TERM COMPLICATIONS 1…Ailing Implants. 2…Failing implants. 3…Failed implants.
  74. 74. The factors for long term complication could be: 1--- Nutrition 2--- Age related factors 3--- Factors secondary to systemic diseases 4--- Bruxism 5--- Traumatic Occlusion. 6--- Improperly designed superstructures. 7--- Unacceptable oral hygiene. 8--- A physiologically incompetent implant design.
  75. 75. Ailing Implant  The ailing implant is the least seriously affected Implants.  Nothing more than a radiographic evidence of diminishing but static bone loss may direct the implantologist to be suspicious.
  76. 76. Failing Implant  The failing implants are firm. Osseointegration develops apically and is responsible for the implants stability. Routine radiography reveals progressive bone loss around the cervical areas of the implant. BONE RESORPTION……..
  77. 77.  Failing implants  Actinobacillus actinomycetemcomitans  Porphyromonas gingivalis  Prevotella intermedia
  78. 78. Failed Implant  The simplest definition of a failed implant is mobility. This can be diagnosed by: 1… Tapping and receiving a dull sound. 2… Manipulating by two mirror handles and detecting movement. 3… By the use of the Periotest and eliciting a response of +9 or higher.
  79. 79. Keys to Success  1) Take in consideration maintenance liability and health of bone.  2) Give consideration to angiogenesis and blood supply.  3) Do plan the final prosthesis before starting the case.
  80. 80. TEN COMMANDEMENTS OF OSSEOINTEGRATION (Henry P.)  1.Thoug shall not violate biocompatibility  2.Thougshall not compromise implant design  3.Though shall respect implant surface microstructure  4 .Thou shalt address the status of the implant bed  5.Thou shalt utilizeatraumatic surgical techniques  6.Thou shalt formulate optimal loading conditions  7. Thou shalt create acceptable soft tissue interface and esthetic harmony  8. Thou shalt monitor and maintain all restorations  9.Thou shalt love thy neigbour as thyself  10.thou shalt not bear false witness
  81. 81.  Penny wise – pound foolish  Daily floss your implant tooth
  82. 82.  THANK -U

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