Surgical AP in Implant 21.07.09

SURGICAL CONSIDERATIONSURGICAL CONSIDERATIONIN IMPLANTOLOGYIN IMPLANTOLOGY

Dr.Dr. Boworn KlongnoiDr.Dr. Boworn Klongnoi

Treatment conceptsTreatment concepts

• Patient driven concept ?

• Surgeon driven concept ?

• Prosthodontist driven concept ?

?

General in dental implantGeneral in dental implant

A proper planning is important for A proper planning is important for

obtaining an acceptable final resultobtaining an acceptable final result Complete treatment plan needs Complete treatment plan needs

consultation from both consultation from both surgeon surgeon

and and prosthodontistprosthodontist Surgeon should also has the Surgeon should also has the

knowledge of prosthodontic knowledge of prosthodontic

planning planning

OsteointegrationOsteointegration

Direct bone deposition on the Direct bone deposition on the

implant surface without implant surface without

intermediate fibrous tissue or intermediate fibrous tissue or

fibrocartilage formationfibrocartilage formation

““Functional ankylosis”Functional ankylosis”

Bone regenerationBone regeneration

Sequence of bone Sequence of bone

regenerationregeneration- Immediate Immediate

(Inflammatory) response (Inflammatory) response

- Bone formationBone formation

- Bone remodalingBone remodaling


Blood clotBlood clot holds a pool of holds a pool of

chemoattractive and mitogenic chemoattractive and mitogenic

growth factorsgrowth factors- PDGFPDGF

- TGF-TGF-β β - VEGFVEGF

Blood clot provides a temporary Blood clot provides a temporary

extracellular matrix on which extracellular matrix on which

cells can growcells can grow


Bone marrowsBone marrows

SurroundingSurrounding Mesenchymal progenitor cellsMesenchymal progenitor cellsCirculationCirculation

Soft tissue Soft tissue

PeriosteumPeriosteum

Haematoma Haematoma Vessel- and collagen formationVessel- and collagen formation Mineralisation of collagenMineralisation of collagen Bone maturationBone maturation RemodellingRemodelling

Anatomical fundamentalsAnatomical fundamentals

REM: Aggregation auf der Kollagenmatrix

De novo bone formation on implant surfacesDe novo bone formation on implant surfaces

1. early osteopontin expression at initial cement layer formation

2. collagen matrix on the cement layer is mineralised by alc. phosph. and BSP

3. osteocalcin and osteopontin expression at initial mineralisation

4. osteopontin essential part of the organic bone matrix beneath the lining cells and surrounding the

osteocyt lacunas

praeosteoblast

osteoblast

osteocyte

lining cells

cement layer

implant

new formed bone

osteocalcin activated by Cbfa1

osteopontin

bone sialoprotein

osteopontin

osteopontin

alcal. phosphatase

collagen

Sodek,J. und Cheifetz,S.: Molecular Regulation of Osteogenesis, aus Bone Engineering; em squared incorporated, Toronto, Canada;37 (1999 )

Cbfa1

Healing of endosseus implantsHealing of endosseus implants

Osteoconduction

Migration of osteogentic cellsto the implant surface

De novo bone formation - contact osteogenesis

Remodelling

Prerequisites for osteointegrationPrerequisites for osteointegration

1. Precise fitting 1. Precise fitting

(design and inserting techniques)(design and inserting techniques)

2. Primary stability2. Primary stability

3. Adequate loading (Biomechanics)3. Adequate loading (Biomechanics)

4. Bioinert / bioactive materials4. Bioinert / bioactive materials

5. Proper surface configuration 5. Proper surface configuration

Precise fittingPrecise fitting

ShapeShape SurfaceSurface Retention formRetention form

Cortical bone osteointegrationCortical bone osteointegration

Maximum direct bone-implant contactMaximum direct bone-implant contact Press-fitting phenomenonPress-fitting phenomenon Cause Cause local overloadlocal overload Overload -> microcrack, fissureOverload -> microcrack, fissure Bone becomes avascular and necrotic Bone becomes avascular and necrotic

in early stagein early stage In second stage - bore hole replace by In second stage - bore hole replace by

lamella bone in 3 monthslamella bone in 3 months In 15 months - 60-70% living bone In 15 months - 60-70% living bone

contactcontact

Cancellous bone osteointegrationCancellous bone osteointegration

Provide less primary stabilityProvide less primary stability Only 20-25% density compare to Only 20-25% density compare to

compact bonecompact bone Vascular rich / osteoblast richVascular rich / osteoblast rich Divided into two area Divided into two area

1. Trabeculae contact1. Trabeculae contact

2. Marrow contact2. Marrow contact

Stages of implant surgeryStages of implant surgery

1. Two stages surgery1. Two stages surgery

2. One stage surgery2. One stage surgery

3. Immediate function3. Immediate function

Non-Submerged Method

(One-stage implant)

Submerged Method(Two-stage implant)

Possibilities of loadingPossibilities of loading

Alveolus healingAlveolus healing periimplant bone healing functional loading periimplant bone healing functional loading

extra

ction

impla

ntat

ion

reen

try

* Schliephake; Konzepte zur Verkürzung der Behandlungsdauer. Implantologie; 9/4: 357-372 (2001)

Immediate implantation + immediate loading

Immediate implantation + shortened healing phase

Immediate implantation + standard healing

delayed implantation + shortened healing phase

delayed implantation + standard healing phase

tt

immediate-, rsp. early loadingimmediate-, rsp. early loading

biologicalbiological

mechanicalmechanical

implant retention

1. Two stages surgery1. Two stages surgery

Widely acceptable procedureWidely acceptable procedure

stage I : Implant fixture placementstage I : Implant fixture placement

stage II : Soft tissue exposure for abutment stage II : Soft tissue exposure for abutment

placement period between both placement period between both

stage depends on bone quality stage depends on bone quality

BoneBone

Higher failure rate is sometimes Higher failure rate is sometimes

encountered in type I and II boneencountered in type I and II bone

OverheatOverheat

Optiomal drill spead / irrigation / Optiomal drill spead / irrigation /

pretappingpretapping

Implant site preparationImplant site preparation

If the temperature of the bone exceeds If the temperature of the bone exceeds

47 C for 1 minute, bone resorption and 47 C for 1 minute, bone resorption and

fat cell degeneration occursfat cell degeneration occursEriksson and Albrektsson 1983Eriksson and Albrektsson 1983

Dense bone Dense bone : 1500 rpm: 1500 rpm

Cancellous boneCancellous bone : 800 rpm: 800 rpmMisch 1993Misch 1993

Bone tappingBone tapping

Recommended for cases in which the Recommended for cases in which the

bone is dense, compact and poorly bone is dense, compact and poorly

vascularized (Type I or II)vascularized (Type I or II) Not recommended for type III or IVNot recommended for type III or IV

OverpreparationOverpreparation

Fibrous encapsulationFibrous encapsulation

Implant site preparationImplant site preparation

Overheating the bone is due to 3 Overheating the bone is due to 3

factorsfactors- Using dull drillUsing dull drill

- Inadequate irrigationInadequate irrigation

- Torquing or drilling at high speedTorquing or drilling at high speed

Collins and Collins 1998Collins and Collins 1998

Implant insertionImplant insertion

PrinciplePrinciple- Primary stability is requiredPrimary stability is required- No excessive forceNo excessive force- For screw-implant : 10-20 rpmFor screw-implant : 10-20 rpm

20-50 Ncm20-50 Ncm

Selection length of the fixtureSelection length of the fixture

Anatomical limitation : Anatomical limitation :

1. Inferior alveolar nerve1. Inferior alveolar nerve

2. Maxillary sinus2. Maxillary sinus

3. Bone mass3. Bone mass

Anchorage neededAnchorage needed

Tip size by drill diameter

Drill Tip

L= - c - sL= - c - sHHMM

L= L= – 2 – 2 = 8 – 2 – 2 = 815155/45/4

Prediction for proper direction of fixture :Prediction for proper direction of fixture :

There are many way to determineThere are many way to determine

1. Surgical stent1. Surgical stent

2. Guide pin2. Guide pin

3. Occlusion3. Occlusion

4. Teeth adjacent to the space4. Teeth adjacent to the space

5. Intraop. X-Ray5. Intraop. X-Ray

Importance of correct directionImportance of correct direction

Correct prosthetic-implant Correct prosthetic-implant

angulationangulation

Correct loading transferCorrect loading transfer

Correct intercoronal distanceCorrect intercoronal distance

Correct path of prosthetic insertionCorrect path of prosthetic insertion

Stage II procedureStage II procedure

Keep keratinized tissue as Keep keratinized tissue as

important pointimportant point

Create interdental papillae when Create interdental papillae when

possible - in esthetic areapossible - in esthetic area

Abutment selection Abutment selection

BoneBone

Long-term success of dental implants Long-term success of dental implants

appears to be highly dependent on appears to be highly dependent on

both quality and quantity of the both quality and quantity of the

available boneavailable boneJaffin Ra, Berman CL 1991Jaffin Ra, Berman CL 1991

Jaw shape and bone quality must be Jaw shape and bone quality must be

regarded as the regarded as the most influential factorsmost influential factors

affecting implant survivalaffecting implant survivalFriberg et al 1991Friberg et al 1991

Edentulous mandible and maxillaEdentulous mandible and maxillaClassificationClassification Bone Quanlity Bone Quanlity

1 1 The entire mandible/maxilla is composed of The entire mandible/maxilla is composed of

homogeneous compact bone.homogeneous compact bone.

22 A thick layer of compact bone surrounds a A thick layer of compact bone surrounds a

core of dense trabecular bone.core of dense trabecular bone.

33 A thin layer of cortical bone surrounds a core A thin layer of cortical bone surrounds a core

of low-density trabecular bone of favorable of low-density trabecular bone of favorable

strength.strength.

44 A thin layer of cortical bone surrounds a core A thin layer of cortical bone surrounds a core

of low-density trabecular bone.of low-density trabecular bone.

Lekholm U, Zarb GA 1985Lekholm U, Zarb GA 1985

Edentulous mandible and maxillaEdentulous mandible and maxilla

ClassificationClassification Bone QuantityBone Quantity

A A Most of the alveolar ridge is present.Most of the alveolar ridge is present.

BB Moderate ridge resorption has occured.Moderate ridge resorption has occured.

CC Advanced alveolar ridge resorption has Advanced alveolar ridge resorption has

occurred, and only nasal bone remains.occurred, and only nasal bone remains.

DD Some resorption of the basal bone has taken Some resorption of the basal bone has taken

place.place.

EE Extreme resorption of the basal bone has Extreme resorption of the basal bone has

taken place.taken place.

Lekholm U, Zarb GA 1985Lekholm U, Zarb GA 1985

Surgery department

Dental faculty

Mahidol University

Maxilla vs. MandibleMaxilla vs. Mandible

MaxillaMaxilla- Healthy :Healthy : Type II-III, Jaw shape A-CType II-III, Jaw shape A-C

- Resorbed :Resorbed : Type III-IV, Jaw shape D-EType III-IV, Jaw shape D-E

- Limitation :Limitation : Maxillary sinusMaxillary sinus

MadibleMadible- Healthy :Healthy : Type I-II, Jaw shape A-CType I-II, Jaw shape A-C

- Resorbed :Resorbed : Type I-III, Jaw shape D-EType I-III, Jaw shape D-E

- Limitation :Limitation : Mandibular canalMandibular canal

Bone morphology forBone morphology for implant placement implant placement

planning planning

Bone resorptionBone resorption

Change of angle classChange of angle class

Change of intermaxillaryChange of intermaxillary

distancedistance

physiological tooth axis

implant axis at labial bone resorption

DefectDefect

Bone?Bone?

Soft tissue?Soft tissue?

Guided bone regeneration Guided bone regeneration Bone condensing, spreading, splittingBone condensing, spreading, splitting Autogenous bone graft Autogenous bone graft Bone substituteBone substitute Sinus lift Sinus lift Nerve transpositioningNerve transpositioning Interpositional bone graftInterpositional bone graft Microvascular free flap Microvascular free flap

Several surgical techniques available Several surgical techniques available

for correction of atrophic ridge for correction of atrophic ridge

Guided tissue regenerationGuided tissue regeneration

Osteopromotion systemOsteopromotion system

Promote osseous healing Promote osseous healing

in defectin defect

Exclude non-osteogenic Exclude non-osteogenic

soft tissue from defect soft tissue from defect

healinghealing

Guided tissue regenerationGuided tissue regeneration As soft tissue support and prevention for As soft tissue support and prevention for

collapse of spacecollapse of space Creation of clot space provide osteogenic cells Creation of clot space provide osteogenic cells

migrationmigration Protection of granulation tissueProtection of granulation tissue Promote vascular network formationPromote vascular network formation

Ideal position for GTRIdeal position for GTR

No restorative material

No restorative material

CollapseCollapse

Bone condensingBone condensing

PrinciplePrinciple- Nonablative implant bed preparationNonablative implant bed preparation- Condensation of spongiosa at bone-Condensation of spongiosa at bone-

implant contactimplant contact- Alveolar ridge extension Alveolar ridge extension horizontallyhorizontally and and

verticallyvertically IndicationIndication

- To improve primary stability in To improve primary stability in DD33, D, D44 bone bone density density

- Thin alveolar ridge (>3 mm)Thin alveolar ridge (>3 mm)- Closed sinus liftClosed sinus lift

Bone condensingBone condensing

ProceduresProcedures- IncisionIncision- Initial preparatonInitial preparaton

Lindemann-burLindemann-bur

- Apply bone condenser Apply bone condenser instrumentinstrument

- Preparation of implant bedPreparation of implant bed

Bone spreadingBone spreading

PrinciplePrinciple- Nonablative implant bed Nonablative implant bed

preparation as well as preparation as well as alveolar ridge extensionalveolar ridge extension

- Condensation of Condensation of spongiosaspongiosa at bone- at bone-implant contactimplant contact

IndicationIndication- Thin alveolar ridge (at Thin alveolar ridge (at

least 3 mm)least 3 mm)- Bone density DBone density D33 and D and D44


InstrumentsInstruments- Standard surgical setStandard surgical set

- Standard implant setStandard implant set

- Bone condenser setBone condenser set Osteotome set (Steri Os)Osteotome set (Steri Os) Bone condenser (Dentsply Friadent)Bone condenser (Dentsply Friadent) Summers Osteotome set (Implant Innovations)Summers Osteotome set (Implant Innovations) Dilatatoren set (Osteo Ti)Dilatatoren set (Osteo Ti)


PreceduresPrecedures- Incision & Flap preparationIncision & Flap preparation

Parapapilla incisionParapapilla incision Crestal incisionCrestal incision

- Cortical osteotomyCortical osteotomy Fine Lindemann-bur, DiscFine Lindemann-bur, Disc A width of 2-4 mmA width of 2-4 mm

- Pilot drill at center of alveolar Pilot drill at center of alveolar

ridgeridge Lindemann-burLindemann-bur

Bone spreadingBone spreading ProceduresProcedures

- Apply bone condenser Apply bone condenser

instrumentsinstruments Use the instrument Use the instrument step-by-stepstep-by-step Apply through pilot hole until the Apply through pilot hole until the

expected depthexpected depth Rotation and anteroposterior Rotation and anteroposterior

extensionextension Stop the manuveurs if the alveolar Stop the manuveurs if the alveolar

ridge width is adequate for ridge width is adequate for

implant placementimplant placement

- Preparation of implant bedPreparation of implant bed Last implant preparation burLast implant preparation bur

Segmental bone splittingSegmental bone splitting

PrinciplePrinciple- Pre / Intraimplantation osteotomy of Pre / Intraimplantation osteotomy of

alveolar ridge bucco-linguallyalveolar ridge bucco-lingually- Mobilisation of segments in transverse Mobilisation of segments in transverse

directiondirection IndicationIndication

- Atrophic alveolar ridge width (2 mm)Atrophic alveolar ridge width (2 mm)- Adequate bone heightAdequate bone height


Instruments and materialsInstruments and materials- Standard surgical setStandard surgical set

- Standard implant setStandard implant set

- Diamond discDiamond disc

- ChiselsChisels

- Bone condenser setBone condenser set

- Bone substitues (if need)Bone substitues (if need)

Segmental bone splittingSegmental bone splitting ProceduresProcedures

- Incision and flap preparationIncision and flap preparation- Osteotomy of cortical boneOsteotomy of cortical bone

Diamond discDiamond disc Distance from neighbouring teeth Distance from neighbouring teeth ~ ~ 1 mm1 mm Osteotomy at midcrestal bone and mesial/distalOsteotomy at midcrestal bone and mesial/distal

- Splitting the alveolar ridgeSplitting the alveolar ridge ChiselsChisels Green-stick fractureGreen-stick fracture

- Preparation of implant bedPreparation of implant bed Stability mostly from lingual sideStability mostly from lingual side


ProceduresProcedures- Fixation of segment (with plate and screws)Fixation of segment (with plate and screws)

- Periimplant / Interlamellar bone Periimplant / Interlamellar bone

augmentation augmentation Autogenous boneAutogenous bone Bone substituesBone substitues

Bone augmentationBone augmentation

5 mm.5 mm.

3 mm.3 mm.

Bone graftBone graft

Autogenous bone graft are considered to Autogenous bone graft are considered to be the “gold standard”be the “gold standard”

AdvantagesAdvantages• No risk of immunological rejectionNo risk of immunological rejection• No risk of disease transmissionNo risk of disease transmission• Osteoinductive and osteoconductive potentialOsteoinductive and osteoconductive potential• Source of osteoprogenitor cellsSource of osteoprogenitor cells

Burchardt 1983,Hirsch and Ericsson 1991,Lundgren et al 1996,Raghoebar et al 1993,Wood and Moore 1988

Autogenous bone graftAutogenous bone graft

Disadvantages Disadvantages

Limited amount of graft available in Limited amount of graft available in

intraoral donor sitesintraoral donor sites

The need for a general anesthesia and The need for a general anesthesia and

hospitalization in extraoral donor siteshospitalization in extraoral donor sites

Additional surgical sites Additional surgical sites

Donor site morbidity Donor site morbidity

Laurie et al 1984,Nkenke et al 2001,Nkenke et al 2002,Nkenke et al 2004,Younger and Chapman 1989


Using bone substitutes avoids or Using bone substitutes avoids or reduces problems associated with reduces problems associated with autogenous bone graft harvestingautogenous bone graft harvesting

Ideal grafting characteristicsIdeal grafting characteristics The ability to produce bone by The ability to produce bone by cellular proliferationcellular proliferation from from

viable transplanted osteoblasts or by osteoconduction of cells viable transplanted osteoblasts or by osteoconduction of cells along the graft‘s surfacealong the graft‘s surface

The ability to produce bone by The ability to produce bone by osteoinductionosteoinduction of recruited of recruited mesenchymal cellsmesenchymal cells

RemodelingRemodeling of the initially formed bone into mature lamellar of the initially formed bone into mature lamellar bonebone

MaintainanceMaintainance of the mature bone over time without loss of the mature bone over time without loss through function through function

The ability to The ability to stabilize implantsstabilize implants when placed simultaneously when placed simultaneously with the graftwith the graft

Low infectionLow infection rate rate EaseEase of availability of availability Low antigenicityLow antigenicity High level of High level of reliabilityreliability

Bone graftBone graft Sinus lift in 94 Pt., 362 ImplantsSinus lift in 94 Pt., 362 Implants 9 types of bone grafting materials9 types of bone grafting materials

- Autogenous boneAutogenous bone- DFDBA (Lifenet)DFDBA (Lifenet)- Calcium carbonate (Biocoral)Calcium carbonate (Biocoral)- Bioactive glass (Bioglass)Bioactive glass (Bioglass)- Polymer of polylactic & polyglycolic acids Polymer of polylactic & polyglycolic acids

(Fisiograft)(Fisiograft)- Bovine-derived bone and peptide (Pepgen P-15)Bovine-derived bone and peptide (Pepgen P-15)- Calcium sulfate (Surgiplaster sinus)Calcium sulfate (Surgiplaster sinus)- Bovine deproteinized bone (Bio-Oss)Bovine deproteinized bone (Bio-Oss)- Hydroxyapatite (Fingranule)Hydroxyapatite (Fingranule)

Scarano et al 2006Scarano et al 2006


Scarano et al 2006Scarano et al 2006

100 %100 %

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Bone substitueBone substitue

New boneNew bone

Auto.boneAuto.bone

Maxillary sinusMaxillary sinus

Maxillary sinus is a pyramid-Maxillary sinus is a pyramid-shaped cavity with its base shaped cavity with its base adjacent to the nasal wall adjacent to the nasal wall and apex pointing to the and apex pointing to the ZygomaZygoma

Adult sinusAdult sinus• 2.5 – 3.5 cm. wide2.5 – 3.5 cm. wide• 3.6 – 4.5 cm. tall3.6 – 4.5 cm. tall• 3.8 – 4.5 cm. deep3.8 – 4.5 cm. deep• Volume 12-15 cmVolume 12-15 cm33

Van den Bergh et al 2000Van den Bergh et al 2000

HistoryHistory

Maxillary sinus graft was first described Maxillary sinus graft was first described

by Tatum at Alabama implant by Tatum at Alabama implant

conference in 1976conference in 1976 First published by Boyne & James in First published by Boyne & James in

19801980 Osteotome technique Osteotome technique was described was described by by

Summers in 1994Summers in 1994

Sinus liftSinus lift PrinciplePrinciple

- - Elevation of Schneiderian membraneElevation of Schneiderian membrane to to

recontour the sinus in the cranial direction recontour the sinus in the cranial direction

and followed by and followed by bone graftbone graft

IndicationIndication- Insufficient alveolar height of post. maxilla Insufficient alveolar height of post. maxilla

- Optimal interarch spaceOptimal interarch space

Sinus liftSinus lift ProceduresProcedures

- Incision and flap preparationIncision and flap preparation- Osteotomy to perform a bone windowOsteotomy to perform a bone window

Round diamond burRound diamond bur Preventing tear of sinus membranePreventing tear of sinus membrane

- Elevation of Schneiderian membraneElevation of Schneiderian membrane- If residual ridge ≥ 4 mm : Simultaneous If residual ridge ≥ 4 mm : Simultaneous

implantation is possibleimplantation is possible Misch 1987, Watzek 1996, Ulm et al 1995Misch 1987, Watzek 1996, Ulm et al 1995

- Bone augmentationBone augmentation

Sinuslift Consensus Conference, Nov.96, Babson College, Ma, USA,

special supplement JOMI, Vol.13, 1998

1107 Sinus augmentationen

2997 Implantation 229 Implants loss

Simultaneosimplantation

2-Stageimplantation

0 20 40 60 80 100

84.5 %

93.1 %

Sinuslift Consensus Conference, Nov.1996, Babson College, Ma, USA

5-year survival rate of implants 5-year survival rate of implants

AuthorAuthor

BlomqvistBlomqvist

BlockBlock

FugazzottoFugazzotto

KhouryKhoury

KüblerKübler

LekholmLekholm

LorenzettiLorenzetti

OlsonOlson

Peleg (a)Peleg (a)

Peleg (b)Peleg (b)

Peleg Peleg

RaghoebarRaghoebar

RaghoebarRaghoebar

SmedbergSmedberg

v. d. Berghv. d. Bergh

WannforsWannfors

WannforsWannfors

WatzekWatzek

WiltfangWiltfang

ZitzmannZitzmann

Number of Number of sinus liftssinus lifts

9797

2727

167167

216216

3939

4747

??

4545

6363

2424

2020

9898

182182

7575

6060

??

??

1414

6363

3030

Year

1998

1998

2002

1999

1999

1999

1998

2000

1999

1999

1998

1999

2001

2001

1998

2000

2000

1998

1999

1998

Number of Patients

50

16

150

216

23

47

13

29

63

21

20

52

99

39

42

20

20

7

53

30

Number of Implants

201

73

167

467

67

181

?

120

160

57

55

204

392

207

161

76

74

53

132

79

F/U

50

72

36

49

24-48

36

?

38,2

24-48

8-10

26,4

32

12-124

36

12-72

12

12

70

24

30

Implant

Survival rate

84,2%

95,9%

97,8%

94,0%

94,1%

76,0%

?

97,5%

100,0%

100,0%

100,0%

93,3%

91,8%

100,0%

100,0%

79,0%

89,0%

95,4%

95,0%

95%-100%

Implant-ation

sec

sim

sec

sim

sim/ sec

sim

sec

sim/ sec

sim

sim

sim

sec

sec

sim

?

sim

sec

sec

sim

sim/ sec

sim: 1629 sec: 1224

TotalTotal 994 12401240 2853 93,59 %

Sinus lift & Implant survival ratemplant survival rate

Nerve transpositioningNerve transpositioning

PrinciplePrinciple- Transposition of inferior alveolar nerve to Transposition of inferior alveolar nerve to

achieve primary stability without bone achieve primary stability without bone augmentationaugmentation

IndicationIndication- Inadequate alveolar height of posterior Inadequate alveolar height of posterior

mandiblemandible- Optimal interarch spaceOptimal interarch space- Compression of mental nerveCompression of mental nerve

Distraction osteogenesisDistraction osteogenesis

PrinciplePrinciple- Controlled, gradual vital bone regeneration Controlled, gradual vital bone regeneration

between osteotmy segmentsbetween osteotmy segments- Increase alveolar ridge height without bone Increase alveolar ridge height without bone

graftgraft IndicationIndication

- Vertical alveolar atrophyVertical alveolar atrophy- Adequate bone widthAdequate bone width- Open biteOpen bite

Microvascular free flapMicrovascular free flap

Local or regional tissues are unavailable or inadequateLocal or regional tissues are unavailable or inadequate

Application of locoregional tissues would result in Application of locoregional tissues would result in

significant or esthetic losssignificant or esthetic loss

When bone reconstruction is requiredWhen bone reconstruction is required

Pt. must withstand a long operative proceduresPt. must withstand a long operative procedures

Post-surgical interim prosthesis managementPost-surgical interim prosthesis management

Relieve acrylic in area of implantRelieve acrylic in area of implant Reline with tissue conditionerReline with tissue conditioner Avoid loading by all means Avoid loading by all means Avoid wearing in 1st-2nd weeksAvoid wearing in 1st-2nd weeks Soft dietSoft diet Daily gentle cleansing Daily gentle cleansing

Soft tissue managementSoft tissue management

Flap designFlap design

Modified palatal roll technique Modified palatal roll technique

Free gingival graft Free gingival graft

Connective tissue graftConnective tissue graft

Vascularized interpositional periosteal-Vascularized interpositional periosteal-

connective tissue (VIP-CT) flapconnective tissue (VIP-CT) flap

Papilla regenerationPapilla regeneration

Membrane Membrane

Flap designFlap designPrinciplePrinciple

Preserve blood supplyPreserve blood supply Preserve the topographic of alveolar ridge and Preserve the topographic of alveolar ridge and

mucobuccal fold mucobuccal fold Identification of important anatomic structuresIdentification of important anatomic structures Provide access for implant instrumentation and Provide access for implant instrumentation and

use of surgical guidesuse of surgical guides Provide access for harvesting of local boneProvide access for harvesting of local bone Provide for closure away from implant or tissue Provide for closure away from implant or tissue

augmentation sitesaugmentation sites Minimize bacterial contaminationMinimize bacterial contamination Facilitate circumferential closure around Facilitate circumferential closure around

permucosal implant structurespermucosal implant structures

Flap designFlap design

Buccal (Facial) flapBuccal (Facial) flap

a: - submerged implanta: - submerged implant

b: - nonsubmerged implantb: - nonsubmerged implant

- abutment connection - abutment connection

Papilla reflectionPapilla reflection

IndicationIndication- Immediate implant placementImmediate implant placement- No need of augmentationNo need of augmentation

Parapapilla incisionParapapilla incision

IndicationIndication- Immediate / Delayed implantationImmediate / Delayed implantation

- Limited defect only coronallyLimited defect only coronally

Parapapilla incision with vestibular extensionParapapilla incision with vestibular extension

IndicationIndication- Immediate / Delayed implantationImmediate / Delayed implantation- Alveolar ridge defectAlveolar ridge defect

U-shaped peninsula flapU-shaped peninsula flap

IndicationIndication- Esthetic implant siteEsthetic implant site- Access of the buccal Access of the buccal

aspect is unnecessaryaspect is unnecessary- No need of No need of

augmentationaugmentation- To prevent scarring and To prevent scarring and

soft tisssue recessionsoft tisssue recession

U-shaped peninsula flapU-shaped peninsula flap

(Mid)crestal incision(Mid)crestal incision

Curvilinear incisionCurvilinear incision

IndicationIndication- As trapezoidal flap- As trapezoidal flap

AdvantagesAdvantages- Incorporation with a greater volume of mucosal Incorporation with a greater volume of mucosal

tissue tissue Improving elasticity Improving elasticity- Flexible for flap adaptation or transpositionFlexible for flap adaptation or transposition- Good esthetic resultsGood esthetic results- Allow for correction of hard and soft tissue Allow for correction of hard and soft tissue

defects simultaneous with implatationdefects simultaneous with implatation- Cutback incision reduces the need of periosteal Cutback incision reduces the need of periosteal

releasing incisionreleasing incision

Curvilinear incisionCurvilinear incision

Modified palatal roll techniqueModified palatal roll technique

Free gingival graftFree gingival graft

Connective tissue graftConnective tissue graft

Skin graftSkin graft

VIP-CT flapVIP-CT flap

Papilla regenerationPapilla regeneration

MembraneMembrane

1 week1 week

2 weeks2 weeks

THANK YOU VERY MUCHTHANK YOU VERY MUCH

FOR YOUR ATTENTIONFOR YOUR ATTENTION

Surgical AP in Implant 21.07.09

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Transcript of Surgical AP in Implant 21.07.09