implants final review

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implants final review
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2013-12-10 21:36:39
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implants final review
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  1. Osseointegration
    • P. I. Brånemark, 1985
    • A direct structural and functional connection between ordered, living bone and the surface of a load-carrying implant
    • Definition: ”Direct anchorage of an implant by the formation of bony tissue around the implant without the growth of fibrous tissue at the bone-implant interface
  2. Stage I Surgery
    The initial surgical placement of dental implant(s)
  3. Implant systems
    • Two-stage Systems – “bone level”
    • One-stage Systems – “tissue level”
    • Immediate Load Systems
  4. Stage 1
    • Preop: consent, if LA->oral AB 30 mins, 5 min CHX
    • Sterile: reduce contamination, enhance success, reduce postop infection
    • concepts: atraumatic, min heat, ID vital anatomy, minimize time, primary soft tissue closure
  5. minimize heat/trauma steps
    • incremental diameter increase
    • round, 2mm twist, pilot, 3mm twist, countersink, 3.75mm tap
    • HIGH SPEED 2000RPM w irrigation
    • TAP at 45RPM
    • insertion w slow speed
  6. flap designs
    midcrestal or palatal incision
  7. Primary closure of soft tissue is accomplished by using:
    • vertical mattress or continuous running suture
    • no tension
    • non-dissolving or slow dissolving
  8. post surgery care
    • Compression gauze: 2 to 4 hours
    • Ice: 48 hours
    • NO removable prosthesis for 7 to 10 days
    • NO tissue-born prosthesis for 2 weeks
    • Relined with soft reline material prior to resumption of wearing removable denture
    • Frequent inspection to observe for soft tissue dehiscence, which increases risk for infection
  9. Smoking
    • CO: high Hb affinity, not detected by pulse-ox
    • thrombocytosis->increased blood viscosity
    • Nicotine: inc HR, BP, vasoconstrictor
    • NOT a contraindication but risk factor for marginal bone loss, failure
  10. Diabetes
    • dec tissue integrity, wound healing, infection
    • no difference in implant failure
  11. #1 cause of implant failure
    INFECTION
  12. Bisphophonates
    • IV: inc BRONJ
    • contraindication for implants
    • Oral: not contratindicated, informed consent for risk
    • 3-6mo holiday before placement if using >3 years
    • oral failures from osseointegration(early) or OI maintenence (late) not BRONJ
  13. surgically related BRONJ from ___ months from implant placement
    <6 months
  14. Bone Quality
    • Type I = Anterior mandible
    • Type II = Posterior mandible
    • Type III = Anterior maxilla
    • Type IV = Posterior maxilla
    • Poor quality bone (type IV) has a higher failure rate
  15. Anatomic Considerations
    • Mental nerve: 5mm away from nerve
    • IAN: 2mm away from nerve
    • lingual concavity
  16. Implant Surgical Procedures are dictated by
    Demands of the Definitive Restoration
  17. Tooth to Tooth
    0.5 mm
  18. Tooth to Implant
    1.5 – 2 mm
  19. Implant to Implant
    3 mm
  20. Implant shoulder to buccal plate
    1 – 2 mm
  21. Implant platform :
    2-3mm apical to clinical CEJ
  22. BL implant considerations:
    • housed in bone
    • 1mm facial ^lingual
    • 2mm for anterior
  23. Implant placed in ideal _____ position
    restoratively-driven
  24. bone augmentation procedure should address and assist in the correction of the ____
    soft tissue defect
  25. Attached mucosa (preferred)
    • 1. Provides a “prosthetic-friendly” environment
    • 2. Facilitates OH maintenance required
    • for long-term success
    • 3. Resists recession
    • 4. Maintains predictable levels over time
    • 5. Enhances esthetic blending
  26. Gingival biotype:
    • • Thick & blunted:
    •  Resists recession & reacts to surgical
    • & restorative insults with pocket formation
    • • Thin & scalloped:
    •  Attached soft tissue is minimal
    •  Bony dehiscence & fenestration defects characterize the underlying osseous structure
    •  Reacts to surgical or restorative interventions with ST recession, apical migration of attachment & loss of underlying alveolar volume
  27. Papilla score
    • (Ryser et al 2005):
    • 4=papilla fills the entire interdental space
    • 3=>50% of the space filled
    • 2=<50% of the space filled
    • 1=no papilla present
  28. Surgical guides with radiographic markers
    • – barium impregnated resin or gutta percha with tin foil for facial contours):
    •  Reveal the need for hard tissue augmentation
    •  Allow implant positions to be related to the underlying bone
  29. A/P spread for fully edentulous
    • mandible at least 10mm
    • maxilla at leasat 20mm
    • cantilever not more than 2*AP spread
  30. Fully edentulous implant tx options
    • Removable:
    • • Minimal # of implants:
    • • Mand: 2
    • • Maxilla: 4
    • Fixed:
    • • Minimal # of implants:
    • • Mand: 4-5
    • • Maxilla: 6
    • Interarch Space:
    • • Allow esthetic & structural form
    • • Distance from crest of ridge to occlusal plane:
    • • Posterior single crown or FPD: 5-7 mm
    • • Overdenture: minimum of 15 mm
  31. Overdenture interarch space
    min of 15mm
  32. interach space for single crown or FPD
    5-7mm
  33. “Prosthetically-driven”
    Determine the IDEAL implant position first then, determine feasible implant sites.
  34. Stage II surgery
    • Surgically expose the coverscrew / head of the implant(s)
    • Replace cover screw with a healing abutment
    • Evaluate the surrounding soft tissue contours and quality
    • Create an adequate zone of keratinized-attached mucosa around the implants
    • Partially edentulous:
    • • Esthetic zone
    • • Preserve / Restore gingival contours (especially the interdental papilla)
  35. Adequate zone of keratinized-attached soft tissue facilitates
    • • Plaque control
    • • Oral hygiene is easier and more comfortably
    • • Tissues more likely to remain healthy
  36. inadequate keretinized tissue handling
    • split-thickness flap is re-positioned and sutured to the periosteum
    • inter-implant “exposed” connective tissue areas heal by secondary intention and re-epithelialization
  37. Treatment for lack of keratinized attached tissue on buccal surfaces
    free gingival graft from palate (donor site) to buccal aspect of implants.
  38. implant failure trends
    • max > mand
    • post max >>ant max > post mand > ant mandible
  39. best implant location
    • ant mandible
    • worst: post max
  40.  Osteoconduction
    formation of new bone along a scaffold from the host’s osteocompetent cells
  41.  Osteoinduction
    formation of new bone from the differentiation and stimulation of mesenchymal cells by the bone-inductive proteins
  42.  Osteogenesis
    formation of new bone from osteocompetent cells
  43. ideal graft
    • osteo genic > inductive > conductive
    • maintain vascularity
    • low infection, antigenicity
  44. Remodeling occurs after extraction
    •  Buccal bone loss, narrow horizontal dimensions (unpredictible if needs augmentation or not)
    •  Cortical bone replaced by trabecular bone and bone marrow
  45. What is necessary for superior implant function and esthetics?
    •  Sufficient alveolar bone for ideal implant placement
    •  Favorable alveolar bone architecture
  46. implant Success
    •  < 1 mm bone loss 1 yr, then 0.1 mm per year
    •  No pain, paresthesia, infection
  47. radiographic stent needed for what kind of craniofacial implant?
    auricular
  48. ____ of supraorbital rim is preferred
    • lateral
    • Better bone volume
    • Anatomic restrictions
    • Presence of the frontal sinus
    • Presence of ethmoid air cells
    • Lateral portion of infraorbital rim also possible
  49. nasal defect implant location
    • pyriform rim: 2
    • An additional implant may be placed in the glabella
  50. craniofacial implant survival
    auricular>nasal(81% piriform 25% glabella)>orbit
  51. negative effects of prior radiation are most evident with ______ implants.
    orbital
  52. Recurrent Cemento-ossifying fibroma tx
    partial madibulectomy
  53. Changes following tooth loss
    • • disuse atrophy
    • • hormonal/metabolic action
    • • mucoperiosteal loading by a dental prosthesis
    • • traumatic occlusion from opposing dentition
    • • parafunctional habits
    • • iatrogenic
  54. Maxillary Sinus Lift: Indirect/Osteotome
    • Use of osteotomes to lift single or multiple sites without lifting the entire membrane nor creating a lateral window
    • • Requires > 7-8 mm residual ridge
    • • Often difficult to detect membrane perforations
  55. autogenous harvest complications
    • - temporary/permanent neural disturbances
    • - Ramus: 5%
    • - Chin: 10-50%
    • Extraoral
    • - iliac crest 2% (temporary pain/gait disturbance)
    • - calvarium?
  56. Osteogenesis
    laying down of new bone by osteocompetent cells
  57. Osteoinduction
    primitive, undifferentiated and pluripotent cells are somehow stimulated to develop into the bone-forming cell lineage
  58. Osteoconduction
    bone grows on a surface. An osteoconductive surface is one that permits bone growth on its surface or down into pores or channels (scaffold)
  59. autogenous graft characteristics
    • osteogenic osteoconductive osteoinductive
    • all others just conductive
  60. sinus graft success rates
    alloplast (w or w/o xenograft) > autograft > allograft
  61. Known Benefits of PRP(platelet rich plasma)
    • • Enhances the rate of bone formation? NO!
    • • Enhances the quality of bone? MAYBE!
    • • Enhances the rate and quality of soft tissue healing? YES!
    • • Speeds up surgical time, minimizing trauma? YES!
    • • Eliminates concerns about immunologic reactions and disease transmission? YES!!
  62. Platelet Derived Growth Factor (PDGFJ)
    • • Chemotactic for periodontal ligament cells
    • •Beta-Tricalcium Phosphate Carrier
    • • 2005 FDA approved for intraosseous periodontal defects and associated gingival recession
    • (Gem21S®)
  63. Platelet Rich Fibrin (PRF)
    • Proven improved healing and bone graft handling, less chance of wound dehiscence
    • •No direct correlation between PRF and bone growth
  64. Platelet Rich in Growth Factors (PRGF)
    • Improved soft tissue healing, graft handling, reduced wound dehiscence
    • •No benefit for the final outcome could be shown for it’s use in sinus lift procedures nor in horizontal/vertical augmentations
  65. BMP-2
    • rhBMP-2 causes the chemotactic migration of bone-forming cells to the site of local concentration.
    • rhBMP-2 binds to specific receptors on the stem cell surface causing them to differentiate into bone-forming osteoblasts. But not all BMPs are capable of this binding.
  66. site develepment begins with
    • Augmentation of the Extraction Socket
    • avoid addtl grafting, harvesting
  67. Factors Determining Success of Augmentation Procedure
    • 1.Stabilization (rigid fixation)
    • 2.Vascularity (vascular channels)
    • 3.Cellular survival (20% - 30%)
    • 4.Primary closure (maintained)
    • 5.Undisturbed healing period (1 mo.)
  68. mandibular onlay grafting initial graft height loss
    • 75%
    • complications(28%): wound dehiscence (irreversible
  69. Distraction Osteogenesis
    use of a matured blood clot or immature bone (osteoid) to Regenerate new bone
  70. Alveolar Distraction-Indications
    • partial defects of the alveolar ridge
    • vatrophic bone segments in the mandible and maxilla
    • Orthodontic indications such as:
    • -vertical correction or replacement of dentulous segments
    • -treatment of local open bite
  71. alveolar distraction timeline
    • initial surgery (latency 5-7 days)
    • distraction (3*0.3mm or 2*0.5mm / day)
    • retention (3 months)
    • Extra-Osseous Device: severly resorbed ridges, large, mandible segments
  72. mandibular distraction height loss
    • 20% (4.05/5.22)
    • complications(42%, reversible):

    • temporary paresthesia
    • mucosal hypertrophy
  73. Advantages of Osseous Distraction
    • Bone segment remains vital
    • Low incidence of infection
    • Short treatment period
    • Low incidence of relapse
    • Predictable results
    • High success rates (95%)
    • Generation of soft tissue volume
  74. Ø Particulate and Block bone grafts can
    predictably gain ____ in height
    2 –3 mm
  75. ØAutogenous bone grafts will not provide
    interproximal _______
    soft tissue height
  76. _________ will provide predictable and stable vertical augmentation of alveolar ridge
    and re-establish interproximal papillae when properly osteotomized
    • Distraction Osteogenesis 
    • vs. autogenous bone grafts
    • Distraction Osteogenesis will re-establish interproximal papillae when properly osteotomized
  77. Bone sets the tone but the ___- is the issue
    soft tissue
  78. Implant Surgical Procedures are dictated by
    Demands of the Definitive Restoration
  79. cement vs screw retained
    • cement more proclined
    • screw: retroclined
  80. ovate vs ridge lap crown
    • ovate: proclined
    • ridge lap: retroclined
  81. soft tissue esthetics dictated by
    • adjacent teeth position
    • interproximal bone levels and architecture
    • cervical level of implants
  82. exposure flaps rotated
    mesial or anteriorly
  83. soft tissue defects
  84. Palacci vertical
    • I: intact, slighly reduced
    • II less than 50% loss
    • III: severe papillae loss, interseptal bone loss
    • IV: absence of papilla (edentulous ridge)
  85. UCLA Esthetic Implant Analysis
    • Balance & Harmony of hard and soft tissues
    • tooth positions
    • deficiencies in crown ratios
    • deficiencies of soft tissue contours (papilla)
    • hard tissue deficiencies at cervical margins
  86. Evaluation of Esthetic Zone
    • gingival margin line: Apical portion of gingival
    • margin Canine to Canine
    • papilla line: height of mesial papillae of canines
    • incisal line: incisal edges parallel to gingival margin line
  87. Original Brånemark protocol
    • - Two stage approach
    • - At least 3 months before implant loading
  88. Delayed loading (early loading)
    • fixture placement: 4-6 months (2 months)
    • abutment connection: 3 weeks, soft tissue (0-3 weeks)
    • impression: 1-2 months fabrication (while soft tissue heals)
    • delivery: 6-9 months for completion (3-4 months, no trial period)
  89. osseointegration stability
    • surgery, healing, loading/function
    • mechanical->biolgical stability 3-6 months
  90. ________ of an implant at time of placement is critical for implant success and to decide if a 2-stage system may be converted to a 1-stage system. ______ is even more important when considering using an implant system for Immediate Loading
    The initial stability
  91. initial stability measurement
    • resonance frequency analysis (ISQ)
    • high: >=70, do not increase with time
    • lower increase with bone remodleing, osseointegration
    • ISQ 55 or lower: WARNING, actions to improve should be considered
    • small drop level off ok
    • big drop in stability or a continuing decrease should be taken as a warning sign
  92. improve initial stability
    • ISQ < 55
    • larger implant diameter
    • longer healing time
  93. immediate loading
    • fixture placement: immediate provisionalization
    • abutment connection: soft tissue healing around provisional
    • definitive prosthesis: 1-3 months
    • delivery: definitive after 3 months
  94. immediate loading factors
    • implant stability >70 ISQ
    • surgical technique
    • quality/quantity of bone
    • wound healing
    • implant design: threaded, texture (TiUnite), length
    • Occlusal factors: quality/quantity of force
    • prosthetic design: cross arch splinting, restoration rigidity
  95. Immediate loading benefits
    • Ø  Immediate Function
    • Ø  Shortened treatment times
    • Ø  Minimizes number of surgeries
    • Ø  Less trauma to soft and hard tissues
    • Ø  Easier recovery for the patient
    • Ø  Cost savings to patients and doctors
    • Ø  Improve acceptance rates for treatment
  96. presurgery procedures
    • Make an inter-occlusal record
    • Confirm the VDO
    • Duplicate denture
    • Complete denture for the CT scan
    • Confirm esthetics, phonetics, VDO 
    • Proper fitting complete denture
  97. implant legal stats
    • 5% total claims
    • 12% total payout
    • 13% indemnity paid
  98. Informed Consent
    • •  The diagnosis
    • •  The nature of the proposed treatment
    • •  The type and name of the procedure
    • •  The risks associated with the treatment
    • •  The benefits associated with the treatment
    • •  The alternatives to treatment and associated risks
    • •  The risk of no treatment
  99. Anterior maxilla grafting
    • use of cortical-cancellous blocks:
    • veener: isolated horizontal
    • onlay: vertical
    • saddle: height and width
  100. inlay grafts correct _____ deficiencies
    volume
  101. veneer grafts correct _____ deficiencies
    width
  102. onlay grafts correct ___ deficiencies
    height
  103. saddle grafts correct ___ deficiencies
    height and width
  104. avg healing for bone graft
    3-6 months
  105. graft complications
    • inadequate fixation
    • inadequate soft tissue closure and poor vascularization

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