Introduction To Implant Therapy PDF

INTRODUCTION TO IMPLANT THERAPY - Studies suggest that greater than 90-95% Implant success rates can be expected in healthy patients with good bone and normal healing capacity. - Clinicians must accurately diagnose the current dentoalveolar condition, as well as the overall mental and physical...

INTRODUCTION TO IMPLANT THERAPY - Studies suggest that greater than 90-95% Implant success rates can be expected in healthy patients with good bone and normal healing capacity. - Clinicians must accurately diagnose the current dentoalveolar condition, as well as the overall mental and physical well-being of the patient to determine wether implant therapy is possible or indicated. CASE TYPES AND INDICATIONS - Partially Edentulous Patients 1. Single tooth 2. Multiple teeth - The major advantage of implant- supported restorations in partially edentulous patients is that they replace missing teeth without invasion or alteration of adjacent teeth. - Patients who didn’t have xed options, such as those with Kennedy class I and II, can be restored with implant-supported xed restoration. - Edentulous Patients - These patients can be e ectively restored, both esthetically and functionally, with an implant- assisted removable prosthesis or an implant-supported xed prosthesis. - Options (Examples) (Slide 7) - Full arch implant-supported xed prosthesis In the mandibular arch - Ceramometal implant-supported Fixed prosthesis - Maxillary implant-retained overdenture Bar attachement Pretreatment evaluations: - Chief complaint. - Medical History - A thorough medical history is required for any patient in need of dental - Any disorder that may impair the normal wound healing process, should be carefully considered as possible risk factor or contraindication to implant therapy - If any questions remain, a medical clearance for surgery should be obtained from the treating physician. Contraindications To implant Therapy Unrealistic Expectations IV bisphosphonate Radiation to The site Chemotherapy Treatment Severe psychologic Disorder Age (recommended To wait in Children) Uncontrolled Diabetes Poor oral Hygiene and Compliance Limited jaw Opening DIABETES MELLITUS - Patients with uncontrolled diabetes often experience poor wound healing and increased susceptibility to infections. - A useful test to determine the level of glycemic control over the last 90 days is a blood test gylcosylated hemoglobin (HBA1c). - Normal values for a healthy individuals or diabetic patients under good metabolic control are HBA1c of 8% are under poor metabolic control and have high risk of poor wound healing and infections if dental implants are placed. 1 of 5 ff fi fi fi fi  Medication Related Osteonecrosis of The Jaws (MRONJ) Is a severe adverse drug reaction, consisting of progressive bone destruction in the maxillofacial region. ONJ can be caused by two pharmacological agents: 1) Antiresorptive (including bisphosphonates and RANK-L inhibitors) 2) antiangiogenic. ( such as bevacizumab, sunitinid, or sorafenib ) Procedures reported to have contributed to the development of MRONJ include - Extractions - Root canal treatment - Periodontal surgery - Implant surgery. Implants and surgical procedures, should be avoided in individuals who have been treated with (IV) bisphosphonate and carefully considered with caution in patients treated with oral bisphosphonate, particularly those with the history of more than 3 yrs of use. For patients who have taken oral bisphosphonate for more than 3 yrs, the prescribing provider should be contacted to consider discontinuation of the oral bisphosphonate (drug holiday) for 3 months prior to oral surgery, if systemic conditions permit.The bisphosphonate shouldn’t be restarted until tissue healing has occurred. Osteoradionecrosis of the Jaws (ORN) Patients with a history of radiation treatment to the head and neck may not heal well after surgery. These patients are at risk of developing osteoradionecrosis (ORN) —> a serious condition of non healing exposure —> infection of bone. Surgical procedures are generally avoided in patients with a history of radiation therapy. HABITS AND BEHAVIORAL CONSIDERATIONS A. Smoking and tobacco use A study shows that smokers had a greater risk of implant failure (implant-related odds ratio [OR] of 2.25) compared with nonsmokers. The OR for implant placement with augmentation was 3.61in smokers. The risk of biological complications is signi cantly higher for smokers than for nonsmokers. Why can implants fail in smokers? Carbon monoxide reduces oxygenation of the healing tissue. Nicotine is vasoconstrictive, increasing platelet aggregation and adhesiveness and reducing blood ow. Cytotoxic e ects on broblasts and polymorphonuclear cells disrupt cell repair and defense. Wound healing is impaired, leading to higher complication rate. B. Substance abuse - Drugs and alcohol abuse should be considered a contraindication for implant therapy. Those patients can be irresponsible and noncompliant with treatment recommendations. 2 of 5 fl ff fi fi INTRA-ORAL CLINICAL EXAMINATION DENTAL EXAMINATION A. Arch shape and sizes: this will determine the number and spread of dental implants particularly for edentulous cases. B. Maximun intercuspation, centric relation, occlusal interferences - For partially edentulous patients, the occlusal scheme may be acceptable. But if occlusal changes are necessary, they should be addressed prior to implant placement. C. General wear facets and other signs of parafunctional habits: - Restored implants will have to be protected from these forces, usually by means of occlusal guards. EVALUATION OF EDENTULOUS SPACE The minimum mesial-distal space required for: A. Narrow diameter implant (e.g. 3 mm) is 6 mm B. Standard diameter implant (e.g. 4 mm) is 7 mm C. Wide diameter implant (e.g. 5 mm) is 8 mm The minimum medial-distal space required for 2 standard diameter implants is 14 mm. The minimum amount of interocclusal space required for the restorative “stack” (abutment, abutment screw, crown) on the external hex- type implant is 7mm. For screw retained prosthesis, will require a minimum of 4-5 mm from the implant shoulder to the opposing dentition. PRETREATMENT EVALUATION A. Hard Tissue Evaluation B. Soft Tissue Evaluation - Visualize the presence of attached gingiva using color di erences and tissue mobility by using a periodontal probe to elevate the free mucosa and better visualize the attached tissue. - Debate continues about whether it is necessary to have a zone of keratinized tissue surrounding implants. Despite strong opinions and believes about the need of keratinized mucosa around implants versus this mucosa being unnecessary, neither arguments has been proved. C. Diagnostic Study Models and Wax-up ESTHETIC CONSIDERATIONS - Cases with good bone volume, bone height, and tissue thickness can be predictable in terms of achieving satisfactory esthetic results. - Cases with a high smile line, compromised or thin periodontium, inadequate hard or soft tissues, and high expectations is one of the most di cult challenges in implant dentistry. 3 of 5 ffi ff RADIOGRAPHIC EVALUATION We usually request a PA and Panoramic radiographs or CBCT Important anatomical landmarks in a PAN: Floor and anterior wall of maxillary sinuses. Mandibular canal Floor of the nasal cavities Roots and apices of neighboring teeth The incisive foramen Submandibular fossa Mental foramen The inferior alveolar nerve usually courses anterior to the mental foramen, turning posteriorly and superiorly to exit the mental foramen, creating an anterior loop that is usually 3 mm anterior to the mental foramen. If an implant is to be placed mesial to the level of the mental foramen, the most posterior extent of the implant should be at least 5 mm anterior to the mesial aspect of the foramen. Bony septa arising from the oor of the maxillary sinus are relatively common, occurring in about 33% of the patients. (Underwood 1910) During implant evaluation phase, if the patient’s CBCT reveals an abnormality in one of the maxillary sinuses, refer to ENT for clearance, then proceed with implant surgery. The American Academy of Oral and Maxillofacial Radiology guidelines state that all implant site should be evaluated with a three - dimensional imaging technique such as computed tomography. THE RADIOGRAPHIC TEMPLATE A radiographic template can be used with all radiographic techniques. It’s an acrylic appliance worn by the patient that used to visualize diagnostic teeth or markers on the lms. This appliance can be saved and modi ed into a surgical guide. THE SURGICAL GUIDE - A surgical guide is an acrylic appliance used during surgery that indicated the ideal placement of implants. - There are many methods of fabricating a surgical guide. In consultation with the surgeon, choose the method that you nd most suitable. - A surgical guide can be fabricated by - Duplicating the diagnostic teeth or - By reproducing the long access of each tooth. 4 of 5 fl fi fi fi  Supportive Implant Treatment Implant maintenance begins as the implant becomes exposed to the oral cavity and continues at regular intervals during the life of the implant. The recall interval is determined by the patient’s oral hygiene and susceptibility to plaque induced in ammatory diseases. Initially, for the rst year after treatment, recall maintenance visits should be scheduled at 3 months intervals and then adjusted to suite the patient’s individual needs. EXAMINATION OF DENTAL IMPLANTS Include the following: - Visual inspection. - Digital palpation to detect edema, tenderness, exudation, or suppuration. - Pri-implant probing - Radiographic images can help to verify the level of the peri-implant crestal bone. - Implant stability and percussion testing Radiographs needed: - Taken at implant placement - Abutment connection, and - Final restoration delivery for baseline documentation - and annually. METHODS FOR PROFESSIONAL RECALL MAINTENANCE - Removal of dental plaque and calculus from implant components. - All metal instruments including metal curettes and scalers, and (ultra) sonic scalers, increase surface roughness of polished titanium. - Use of plastic , Te on, carbon and gold- coated curettes, and nonmetal ultrasonic tips have been advocated to protect the titanium implant surface and to reduce the likelihood of scratching the surface. 5 of 5 fl fi fl