Lecture 17, Dental Implants (Script)
Transcript of Lecture 17, Dental Implants (Script)
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Dental Implants
Dental Material II Lecture # 17
* What are the Implants?
They are mainly a type of restoration that is used to replace a missing tooth or a number of
teeth. So you can either use it after extraction of one tooth or two teeth or the entire
dentition. And you want something to fit your restoration in place, so can place a crown on
top of it, a bridge, a complete denture or a partial denture.
It's a relatively new type of restoration, so it's a thirty or a forty-year old type.
So researches are always going on the implants to try and to get the success rate over
decades or a number of years.
This material (the implants) is placed in living tissue (inside bone), so the most importantrequirement is the biocompatibility of this material.
A hole is drilled in the bone and this implant is placed inside so it's going to be part of the
body. So it has to be highly biocompatible or inert and does not cause any irritation or side
effects on the local tissue or the entire system of the human being.
===========================================================================* The parts of the implant. It's mainly composed of 3 parts:
A – The fixture (endosteal root form): the part which goes through
the bone
B – The abutment: the part which is going to support the restoration
C – The actual prosthesis: crown, complete denture, partial denture.
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* Implants Principles:
Before Placement of the implants, we take a radiograph to know the quality of bone, is
there enough bone, thickness and length to place the implant. If the quality of bone is good
to support the implant and the restoration on top, the surgeon will:
1 – Drill a hole in the bone using a titanium alloy- slow speed water-cooled burs.
2- Fix the implants their, and allow it to heal for a few weeks.
3- re-open and placement of abutment caps.
4- Placement of the abutments.
5- Placement of crown or prosthesis.
The important thing about this procedure is that it is a team-effort, so it's done by the co-
operation between the surgeon and the prosthodontist.
In picture (A), the wound is exposed and you can see the upper part of the implants, tissue
are allowed to heal in (B) , in (C) these are the abutment on which the crown will be placed
And then the crown is placed as in (D). So it's a multi-step procedure.
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Some schools or some people say that we can immediately place a load on these implants
before allowing the tissue to heal. And placing a load will even promote more healing.
So it's a debatable issue, but I believe most likely to have tissue healing before actually
loading the implants or allow it to do its function.
===========================================================================
To achieve this unique relationship between the implants and bone, one of two things
might happen (depends on the material of the implant):
1- Osseointegration: there will be very minimal
space between bone and implant (there is no fibrous tissue,there is no PDL), and it's 100 A° (10-10 meter). But it has no
mobility (ankylosis).
This needs to:
1- Biocompatible implant material
2- Atraumatic surgical technique (no trauma or inflammation or contamination)
2- Biointegration: the surface of the implant has a
certain amount of specific material lined on top of it; it can
immediately contact the bone so there will be no space at all.
The surface has some calcium and phosphate material on top of it (same materials that
present in bone), so bone tissue will actually attach to it, this will lead to biointegration.
This requires degradation of the implants, that's mean your implant has a material on its
surface that's going to interact with the bone around it; this will lead to bone deposition
and ion exchange between the implant surface and the bone. This source of reaction will
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cause bone formation directly on the surface of the implant which leads to
biointegration.
* Both lead to successful result, only due to the difference in the material at the surface of the implants *
===========================================================================
Implants can be used to support several type of restoration, but Excessive force can lead to
failure. Because in the natural tooth you have the periodontal tissue which transmitted the
force in a favorable way to the bone in order to prevent bone resorption.
In case of the implant, there is no PDL, no periodontal tissue, and no fluid. This might lead
to direct transmission of the force to the bone which can lead to bone resorption. That's
why the design of your implant or restoration is important; you need to minimize the
amount of force, by increasing the surface area of your restoration for example.
===========================================================================
* Types of Implants
We have 3 types of implants:
A. Subperiosteal : the implants framework is placed
underneath the periostueom
B. Transosteal: the implants framework is placed all the
way through the thickness of the bone from top to bottom.
C. Endosseous: implants framework is placed inside the
bone. It's the most current one and the most commonly used
now. The success rate is much higher and the technique is less traumatic.
===========================================================================
* Implants maybe:
A – Single
B – Multiple
C – Maxillary
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D – Mandibular
E – It can support any type of restoration (depends on the clinical situation)
For example, this is a radiograph showing theimplant inside bone. Here is the abutment that
appears intra-orally, and on top of it the crown is
going to be placed.
So in this case the implant is supporting the
central incisor. So instead of doing a bridge where
you need to drill or prepare the teeth on both sideof the extraction side, you only need to do the implant. So it's more conservative but on the
other hand it's much more expensive.
In other cases, multiple implants are placed to
support a complete denture. Need four to implants
to support it, which will provide good retention and
stability of the denture.
This is a picture of a special tooth brush that's used
to clean underneath the denture. Certain type of
toothbrushes is necessary to maintain a good oral hygiene. It's very important because as
we have peridonititis, there's something called Peri-implantitis (inflammation of the tissue
around the implants).
===========================================================================
* What are the factors that tell you that the procedure has succeeded or the implants are
successful?
1 – No measurable mobility.
2- Good Osseointegrated and biointegrated, which can be partially seen in a
radiograph.
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3- The implant should be able to withstand any force that is subjected to without
mobility.
===========================================================================
* What are the factors that can make a low success rate?1- Irritation or trauma or contamination during the procedure.
2- The bone quality or quantity is not very good.
3- One step placement of the implants ( without a tissue-healing period )
===========================================================================
Q. Can the implants prevent bone resorption?
A. No.
* Implants are expected to last for 10 years
* The bone resorption is a normal process as the patient gets older. The normal rate of the
Ongoing horizontal bone loss is expected (less than 0.5mm/yr). But if it goes beyond that
or it goes vertically, then it indicates a failure of the implants.
* Peri-implantitis: inflammatory process occurring around implants due to microorganisms
similar to those that cause periodontitis.
* Maintaining good oral hygiene is important (tooth brushing, flossing, scaling with plastic
scalers and using mild abrasives).
===========================================================================
* Implants materials:
1- Early material (the older material): it has many disadvantages by
being weak, brittle and cause irritation.
A – Polymers: limited use due to lack of Osseointegration or
Biointegration, and lack of strength.
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Such as:
1- Polymethylmethacrylates
2- Polytetrafluoroethylene (Teflon)
3- Polyethylene
4- Polysulfones
5- Polyurethanes
B- Carbon based material: they have low toxicity but the
problem that's they are too weak and brittle.
2- Current material: are mainly based on titanium. It's a highly
biocompatible material and does not cause any irritation of the soft tissue
or the hard tissue around it.
It could be used pure, but it's better to use it as alloy, because the alloy isstronger than the pure metal.
- Pure titanium: it's 99% pure titanium. It's mixed with a small
amount of oxygen, iron and carbon. All of these elements can
improve properties of the metal.
- Alloy titanium: they alloy it with other material or increase the
amount of some materials.
In this case we add aluminum (6%) and vanadium (4%)
(Melting range and modulus are similar to commercially pure
titanium).
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* Here we have 4 types of the pure titanium but different amount with oxygen; this will
affect the strength and the ductility (قرطلا ةيب) of the material.
* The strongest is grade 4 and the weakest (more flexible) is grade 1.
* We also have the alloys which are even stronger.
So if you want something to support a multi unit bridge or in the posterior area of the
crown, you need an alloy. So it depends on the clinical situation.
In cases of these metallic implants they need to have a certain surface layer that's rich in
oxygen for example or in oxide which will promote a good bonding between the implantsand the bone around it, and prevent the mobility of the implant.
This layer is 20-100 Å. Oxygen rich oxides are closer to the surface and it should be clean
(free of contaminants and bacteria).
* Trace elements from the implant materials maybe released into the surrounding tissue
and maybe found in lungs, liver, spleen but no ill-effect has been reported.
Another type of the implant material is based on ceramics. The good things about
ceramics:
1- Brittle: can withstand high compressive loads but low tensile stresses.
2- High stiffness
3- Inert
4- Function well as Subperiosteal and Transosteal implant
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5- Aluminum oxide based
6- Zirconia based
Now instead of using an implant that's made out of ceramics, they make advantage of this
ceramic material by making it as a liner ( a surface layer on top of the implants ) to
enhance biointegration .
So you got the implant made of titanium alloy, and on the surface there is a layer made out
of a ceramic material or calcium phosphate material.
Now when the implantation is done, ion exchange will occur between the implants and thesurface of the bone which will improve the deposition of calcium and phosphate and bone
formation and intimate contact between the implants and bone.
The thickness of this ceramic layer has to be between 50 – 100 μm.
But there are problems associated with this material; it can become rough with time due to
degradation, so this will promote bacteria colonization which can lead to inflammation andfailure. So sometimes with time this surface layer may become detached from the implant
itself, so delaminating can occur which may lead to more failure.
The coating on the surface can be made out of several
materials such as Hydroxyapatite, tricalcium- phosphate.
All of these can be used as lining material or surface layer material. If the material is more crystalline (less
amorphous) it becomes more resistant to dissolution
(stronger).
this is a represtation to the surface layer that's composed of
tricalcium-phosphate (regaredless of what it is) and this is an example of failuer that might
occur because the surface layer was deattached from the implant surface.
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which means that the benfits of the surface material will be lost because it was seperated
from the implnats .
===========================================================================
* How do you select your implant material?1 – Availability of the implants material around you
2- The strength requirements
3- The quality of bone that you got
4 – The Implant and restoration design
For example, if you need to restore something in the posterior part of the mouth (wherethere is high load) you need for example titanium alloyed or grade (4) titanium.
if got an implant that you have to place it in a freshly extraction socket, which means that
you extracted the tooth and you want to immediately place the implant there you want
something to promote bone formation quickly, so an implant that is lined with ceramics
might be a good choice.
And that's it…Thank you
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Forgive Me For Any Mistake And Sorry For Being Late.
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3eed melad majeed lkol zomla2na elmase7yeen w 5a99a Samer, 6areg w Faris.
Yazeed,,ah Karaki,,,mabsso6 ?!!?
Rafay3a,,,9'al fee lab Prostho aw Cons ma 3awa9'to !!!
If you have 3 words, Mine are unlimted,,,, 7ayeoo ;)
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Done By: Laith Jamal
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