IMPLANTOLOGY

Dr V.RAMKUMAR CONSULTANT DENTAL&FACIOMAXILLARY

SURGEON REG NO: 4118-TAMILNADU-INDIA(ASIA)

What is implant?

A dental implant is an artificial root that replaces the natural tooth root.

Crown

Gum

Implant

Tooth Root

Jawbone

Parts of implant

Cover screw

Implant abutment interface

Implant collar

Fixture

The more teeth that are lost, the greater the impact to your patient’s appearance and psychological well-being.

Tooth loss leads to bone loss - Anterior

Why Dental Implants?

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

Tooth loss leads to bone loss - Posterior

Why Dental Implants?

preserve those two healthy teeth...

Place a single implant and provide a restoration that looks, feels and functions

like a natural tooth

CLINICAL OPTIONS

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

…healthy vital tooth structure.

Dental implants preserve bone and …

Implants are the conservative option.

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

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.

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.

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.

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.

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.

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.

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.

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.

3. Tapered Implants:

Resemble a tooth root. design for both Threaded and Press

fit type Implant. Initially design for immediate

placement into extraction socket.

Pre-Surgical PlanningPre-Surgical Planning

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.

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)

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

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

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

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

Before Placement Of an Implant

Any active endodontic lesions adjacent to the implant site should be treated before endosseous implant placement.

Any active endodontic lesions adjacent to the implant site should be treated before endosseous implant placement.

Overhanging restoration / localized periodontal diseases

periostits

Patient selectionPatient selection

Presentation of Patient:

Mental Status (alertness, coherence, comprehension)

Gait (manner, abnormalities) Overall appearance (neatness, cleanliness) Sign of tobacco and alcohol abuse

Patient’s Attitudes:

Chief complaints Concept of own dental function and appearance Expectations Desired results Oral hygiene Esthetic expectations Desired functional results

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

Proper blood screening and laboratory evaluation

Platelet count PTT PT urinalysis

Diagnostic aids

Panoramic Radiographs Lateral Cephalograms Tomograms and CT scans Mounted Study Cast and Diagnostic Wax-up

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.

Implant Selection

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.

Influence of implant diameter and length on crestal stress distribution

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

Implant Placement Procedure

•Make an incision for elevation of a flap

•Check orientation of the preparation site using direction indicator

•Drill to the appropriate depth

• Drill to the desired depth to enlarge the implant site

•Check orientation of the prepared site using direction indicator

• Drill to the desired depth to enlarge the implant site

• Implant placement with implant driver Select RP

• 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

Direct sinus lift

Complications

Membrane perforation. Presence of bony septae which divide sinus into

separate compartments. Postoperative infection. Wound dehiscence. Barrier Membrane exposure. Transient sinusitis.

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.

Prosthetic phase

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.

Healing abutment/Gingival former

Esthetic abutment

Angled Esthetic Abutment

Multiunit abutment

Ball abutment

Bar supported over denture

Restorative solutions are the Goal

With the internal connection, three broad categories of restorations are possible:

Cement-retained restorations Screw-retained restorations Overdenture restoration

Treatment Alternative

One-stage Immediate Function:

One-stage Delayed Function

Two-stage Delayed Function

One-stage Immediate Function

Procedure overviewrestoring 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

One-stage Delayed Function

The one-stage surgical procedure does not require a second surgical stage, abutments are left protruding through the soft tissue.

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.

1 Abutment connection 2 Impression abutment level

3 Laboratory procedures 4 Final restoration

The importance of the maintenance procedures should never be underestimated by either the patient or the therapist.

Maintenance phase

Implant Hygiene Products

Soft bristle toothbrush Non-abrasive toothpaste Proxy brush Dental floss Electric toothbrushes End-tuft brush Antimicrobial rinses Plastic scalers

Implant Hygiene Products

Why the implants fail…. ?Why the implants fail…. ?

ClassificationClassification

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 Instrumentation6….Hemorrhage.7….Poor angulations & Position of Implant.

PROSTHETIC COMPLICATIONS:

Component & framework breakage

1….Fractured Frameworks & Mesostructure bars2….Partial loosening of cemented bars and prostheses3….Inaccurate fit of castings4….Inadequate Torque application5….In accurate frame work abutment interface6….Occlusal factors7….Implant Fracture8….Implant loss

Short term complications:(

1… Postoperative infection.2… Dysesthesia.3… Dehiscent Implants.4… Radiolucencies.5… Antral complications.6… Implant mobility.

LONG TERM COMPLICATIONS

1…Ailing Implants.2…Failing implants.3…Failed implants.

The factors for long term complication could be:

1--- Nutrition2--- Age related factors3--- Factors secondary to systemic diseases4--- Bruxism5--- Traumatic Occlusion.6--- Improperly designed superstructures.7--- Unacceptable oral hygiene.8--- A physiologically incompetent implant design.

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.

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……..

Failing implants Actinobacillus actinomycetemcomitans

Porphyromonas gingivalis

Prevotella intermedia

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.

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.

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

Penny wise – pound foolish

Daily floss your implant tooth

THANK -U