#18 implant.pdf

Tishik University Faculty of Dentistry Periodontology Department Dr.Omer Naghshbandini DDS, MS, Phd WHOEVER TAUGHT ME A WORD MADE ME HIS SERVANT. Dr. Raul Caffesse Dr. Jim Simon Dental Implant  Introduction Implant dentistry is a complex topic requiring a sou...

Tishik University Faculty of Dentistry Periodontology Department Dr.Omer Naghshbandini DDS, MS, Phd WHOEVER TAUGHT ME A WORD MADE ME HIS SERVANT. Dr. Raul Caffesse Dr. Jim Simon Dental Implant  Introduction Implant dentistry is a complex topic requiring a sound foundation to gain competence in this field Biologic basis of hard and soft tissue interfaces between the implant and surrounding tissues and their clinical relevance MUST be mastered  Biologic Considerations Hard Tissue–Implant Interface Osseointegration is the key biologic and biophysical process that has made dental implant therapy predictably effective. Histologically definition Osseointegration: is the direct structural and functional connection between organized, living bone and the surface of a load-bearing implant without intervening soft tissue between the implant and bone.  Biologic Considerations Soft Tissue–Implant Interface A. connective tissue zone above the crest of the bone contains connective tissue fibers (Sharpey’s) that insert into dentin. The junctional epithelial attachment lined with sulcular epithelium helps form the gingival sulcus. B. Osseointegrated Dental implant  Preoperative General Assessment and Treatment Planning Initial Observations and Patient History Chief complaint relating to potential implants Medical history and risk assessment Dental history Intraoral Examination and Records Diagnostic Casts and Photographs Implant Planning Imaging Intraoral projections: periapical, occlusal Extra-oral: projections eg, panoramic, cephalometric complex cross-sectional imaging: eg, computed tomography [CT], cone-beam computed tomography [CBCT]).  Preoperative General Assessment and Treatment Planning 1. Patient-related factors 2. Operator-related factors 3. Material-related factors  1. Patient-related factors Include and not limited to: Medical background Anxiety Allergy Smoke history Anatomical variations Implant site local challenges Local bone type Local topography Personal preference  Surgical site alveolar deficiency Surgical site evaluation to identify vertical or horizontal deficiency The techniques of management are beyond the scope of this workshop Not all cases would accept manipulating their jaws in a way to reconstruct it back to its original. Important, formulate boundaries in the practice according to what can be done for a patient or what has to be compromised  2. Operator-related factors Expertise Training background Operator’s capabilities Personal interest to introduce new techniques Knowledge of data interpretation The presence of a supporting team Talent to adjust with the challenging case requirement. The code of ethics at any area of practice around the world, the capabilities of practice must be clearly disclosed.  3. Material-related factors Implant surface type, length, diameter, internal design, external design Surgical stents Radiographic imaging Cone beam CT scanning (CBCT) proficiency to manage the Case  Indications For completely edentulous patients with advanced residual ridge resorption For partially edentulous arches where RPD may weaken the abutment teeth In patients with maxillofacial deformities For single tooth replacement where fixed partial dentures cannot be placed Patients who are unable to wear RPD Patient's desire Patients who have adequate bone for the placement of implants  Contraindication Presence of non treated or unsuccessfully treated periodontal disease Poor oral hygiene Uncontrolled diabetes Chronic steroid therapy High dose irradiation Smoking and alcohol abuse  Implant treatment planning Diagnostic modalities used when planning prosthetic and surgical considerations Essential to understand before starting the surgical phase of implant care patients with anatomy requires modification complex situations Advanced forms, various strategies of surgery are necessary  Ridge assessment for delayed placement in healed site.  Delayed Placement in Adequate Bone with Mature Ridge The ridge length (L) The distance between the adjacent teeth The ridge height (H) The height of alveolar ridge available for an implant Occlusal view of the implant Ridge length (L) Width of the ridge (W) The estimated ridge length allows for up to 2- mm clearance from adjacent teeth The minimum ridge width allows for 1-mm thickness of bone on both the buccal and palatal sides of the implant. Minimum ridge length for two implants 2-mm clearance between the adjacent teeth and implants 4-mm clearance between the two implants. Vital structures  Surgical Consideration Implant Placement Tischler guidelines: A. Conservative flap design B. Evaluate the existing bone and soft tissue C. Time the placement correctly D. Visualize the three-dimensional position of the implant  E. Consider healing time before implant loading F. Select a proper abutment and final restoration design  Implant Placement Concept Bone-driven implant placement Restoration driven implant placement Supporting bone influence (Garber DA, Belser UC. Compend Contin Educ Dent 1995;16(8):796, 798–802, 804.) Positional Parameters contribute to the success of the restoration 1. Buccolingual 2. Mesiodistal 3. Apicocoronal 4. Angulation of the implant  Buccolingual Position Buccolingual position Ideal position of implant depends on 1. desired crown location 2. design of the implant 3. design of the abutment  Buccolingual position of implant. Buccal aspect of the implant platform touches an imaginary line that touches the incisal edges of the adjacent teeth.  An implant placed too far palataly Mesio-Distal For maxillary central incisor site, place the implant slightly to the distal to mimic the natural asymmetry of the gingival contour often seen in these teeth. Apicocoronal Position or Countersink Needs to mask the metal of implant Depends on implant diameter The wider the implant, the less distance is needed to form a gradual emergence profile ( Jansen CE, Weisgold A. Compend Contin Educ Dent 1995;16(8):748–52). esthetic VS biology (Cochran DL, Hermann JS, Schenk RK, et al. J Periodontol 1997;68(2):186–98.) Apicocoronal position of implant. Implant platform should be within 2 to 3 mm apical to the mid-buccal gingival margin.  Implant surgery 1. One stage -Coronal portions stays exposed through gingiva during the healing period 2. Two stage –Top of the implant Is completely submerged under gingiva First stage surgical technique 1.Flap design & incision 2.Flap elevation 3.Implant placement 4. Closure of the flap 5. Post operative care  Flap design &Incision Two types of incisions can be used 1. Crestal design- The incision is made along the crest of the ridge, bisecting the existing zone of keratinized mucosa. 2. Remote incision – It is made when bone augmentation is planned to minimize the incident of bone graft exposure. Incision design in implant dentistry based on vascularization of the mucosa Department of Cranio-Maxillofacial Surgery, University of Muenster,Muenster, Germany  Flapless surgery It reduces the post-operative discomfort for the patient and it can also reduce the operative time. This involves tissue-punching a soft tissue access cavity to the bone and placing the implant Flap design &Incision Flap design &Incision Flap design &Incision Flap design &Incision Flap design &Incision Flap design &Incision Remote palatal incisions Advantages of crestal incision less bleeding Easier flap management Less edema Less ecchymosis Faster healing less postoperative vestibular changes  Implant placement One-stage implant surgery Two-stage implant surgery  One-stage implant versus two-stage implant surgeries A, One-stage surgery with the implant designed so that the coronal portion of the implant extends through the gingiva. B, One-stage surgery with implant designed to be used for two-stage surgery. A healing abutment is connected to the implant during the first-stage surgery. C, In the two-stage surgery, top of the implant is completely submerged under gingiva. Tissue management for a two-stage implant placement A, Crestal incision made along the crest of the ridge, bisecting the existing zone of keratinized mucosa. B, Full-thickness flap is raised buccally and lingually to the level of the mucogingival junction. A narrow, sharp ridge can be surgically reduced/contoured to provide a reasonably flat bed for the implant. C, Implant is placed in the prepared osteotomy site. D, Tissue approximation to achieve primary flap closure without tension. Implant site preparation (osteotomy) A, Initial marking or preparation of the implant site with a round bur. B, Use of a 2-mm twist drill to establish depth and align the implant. C, Guide pin is placed in the osteotomy site to confirm position and angulation. D, Pilot drill is used to increase the diameter of the coronal aspect of the osteotomy site  Implant site preparation (osteotomy) E, Final drill (3-mm twist drill )to finish preparation of the osteotomy site F, Countersink drill is used to widen the entrance of the recipient site and allow for the subcrestal placement of the implant collar and cover screw. Note: An optional tap (not shown) can be used following this step to create screw threads in areas of dense bone. G, Implant is inserted into the prepared osteotomy. Note: In systems that use an implant mount, it would be removed prior to placement of the cover screw. H, Cover screw is placed and soft tissues are closed and sutured.  standard drilling protocol vs. adapted bone drilling Undersized Implant Site Preparation (A) Standard drilling protocol (A) Adapted surgical technique for placing implants. Alghamdi et al. Undersized Implant Site Preparation. J Oral Maxillofac Surg 2011  Challenges of implant training vs. Iatrogenic issues Just like anything in life, improper training will lead to disasters. It is imperative to communicate evidence-based clinical application when it comes to health care science Picturing dental implantology as a practice of placing a pin in the bone and then sticking a crown on top is putting the patients and integrity of our profession in a lot of danger Avoid Weak training programs. The importance of basic science, the command of variable methods of practice and scientific understanding of current technology is a MUST for proper training Never Accept shortcuts.  Challenges of implant training vs.Iatrogenic issues All of us in the field would have cases that are not proud of, facing difficult cases, or probably incorrect choice at one time or another. The purpose of showing some of these cases is for educating our self, to avoid some of these difficulties Few examples of cases that could have been done in a better way  Conclusion It is essential to understand and follow basic guidelines to achieve osseointegration predictably. Fundamentals must be followed for implant placement and implant exposure surgery. These fundamentals apply to all implant systems