Download as PDF, PPTX
Uploaded byislam kassem
Dental implants
Dental implants can replace missing teeth by surgically placing artificial titanium fixtures into the jawbone. There are typically two surgical phases - the initial implant placement and a later surgery to uncover the implant after healing. The implant then receives an abutment and final prosthetic restoration. While dental implants can provide many benefits over other tooth replacement options, there are also potential complications at various stages that a dentist must take steps to prevent and manage. Proper patient evaluation, surgical planning and technique, as well as post-operative care are important to achieve successful long-term outcomes.
More Related Content
Similar to Dental implants
Dental implants
- 1. Dental implants Islam Kassem Level 9 [email protected]
- 2. WHAT IS ADENTAL IMPLANT? Dental implant is an artificial titanium fixture which is placed surgically into the jaw bone to substitute for a missing tooth and its root(s).
- 3. History of DentalImplants In 1952, Professor Per-Ingvar Branemark, a Swedish surgeon, while conducting research into the healing patterns of bone tissue, accidentally discovered that when pure titanium comes into direct contact with the living bone tissue, the two literally grow together to form a permanent biological adhesion. He named this phenomenon "osseointegration".
- 4. First Implant Designby Branemark All current implant designs are modifications of this initial design
- 5. Surgical Procedure STEP 1: INITIAL SURGERY STEP 2: OSSEOINTEGRATION PERIOD STEP 3: ABUTMENT CONNECTION STEP 4: FINAL PROSTHETIC RESTORATION
- 6. Fibro-osseous integration • Fibroosseousintegration – “tissue to implant contact with dense collagenous tissue between the implant and bone” • Seen in earlier implant systems. • Initially good success rates but extremely poor long term success. • Considered a “failure” by todays standards
- 7.
- 9. Osseointegration • Success Rates >90% • Histologic definition – “direct connection between living bone and load- bearing endosseous implants at the light microscopic level.” • 4 factors that influence: Biocompatible material Implant adapted to prepared site Atraumatic surgery Undisturbed healing phase
- 10.
- 11.
- 12.
- 13.
- 14.
- 15.
- 16.
- 17.
- 18.
- 19.
- 20.
- 21.
- 22.
- 23.
- 24.
- 25.
- 26.
- 27.
- 28.
- 29.
- 30.
- 31.
- 32.
- 33.
- 34.
- 35.
- 36.
- 37.
- 38.
- 39.
- 40.
- 41. Soft-tissue to implantinterface • Successful implants have an – Unbroken, perimucosal seal between the soft tissue and the implant abutment surface. • Connect similarly to natural teeth-some differences. – Epithelium attaches to surface of titanium much like a natural tooth through a basal lamina and the formation of hemidesmosomes.
- 42. Soft-tissue to implantinterface • Connection differs at the connective tissue level. • Natural tooth Sharpies fibers extent from the bundle bone of the lamina dura and insert into the cementum of the tooth root surface • Implant: No Cementum or Fiber insertion. Hence the Epithelial surface attachment is IMPORTANT
- 44.
- 45. The “Parts” • Implantbody-fixture • Abutment (gingival/temporary healing vs. final) • Prosthetics
- 46.
- 47.
- 48. Surgical Phase- TreatmentPlanning • Evaluation of Implant Site • Radiographic Evaluation • Bone Height, Bone Width and Anatomic considerations
- 49. Basic Principles • Soft/hard tissue graft bed • Existing occlusion/ dentition • Simultaneous vs. delayed reconstruction
- 50. Anatomic Considerations • Ridge relationship • Attached tissue • Interarch clearance • Inferior alveolar nerve • Maxillary sinus • Floor of nose
- 51. Limitations to Implantplacement in the Maxilla • Ridge width • Ridge height • Bone quality
- 52. Anatomic Limitations Buccal Plate 0.5mm Lingual Plate 1.0 mm Maxillary Sinus 1.0 mm Nasal Cavity 1.0mm Incisive canal Avoid Interimplant distance 1-1.5mm Inferior alveolar canal 2.0mm Mental nerve 5mm from foramen Inferior border 1 mm Adjacent to natural tooth 0.5mm
- 53.
- 54. Planning of dental implants [email protected]
- 55. Patient Evaluation • Medicalhistory – vascular disease – immunodeficiency – diabetes mellitus – tobacco use – bisphosphonate use [email protected]
- 56. History of ImplantSite • Factors regarding loss of tooth being replaced – When? – How? – Why? • Factors that may affect hard and soft tissues: – Traumatic injuries – Failed endodontic procedures – Periodontal disease • Clinical exam may identify ridge deficiencies [email protected]
- 57. Functional examination Examination ofsmile: Ackerman et al differentiated between two types of smile: - posed smile (social smile, forced smile) … voluntary, reproducible. - spontaneous smile ( enjoyment smile) … involuntary, induced by joy. [email protected]
- 58. Examination of smile Ackerman et al used a “smile mesh” computer program to analyze photographs of posed smiles using the Occlusal Plane and the Dental Midline as reference planes. He concluded that the posed smile is reproducible if photographs were taken On The Same Day [email protected]
- 59. Smile relatedto natural dentition: (SMILE LINE) - posed smile … the smile-line is at the gingival margin. - lower smile-line … senile appearance. [email protected]
- 60. Smile Line • Oneof the most influencing factors of any prosthodontic restoration • If no gingival shows then the soft tissue quality, quantity and contours are less important • Patient counseling on treatment expectations is critical [email protected]
- 61. SMILE LINE FEMALE MALE MORE GINGIVAL DISPLAY LESS GINGIVAL DISPLAY MORE LOWER INCISOR SHOW [email protected]
- 62. SMILE ARC: -Consonant the curvature of the max. incisors is parallel to that of the lower lip. - nonconsonant the curvature of the max. incisors is flat … senile appearance. [email protected]
- 63. SMILE ARC: NORMAL REVERSE (CONSONANT) [email protected]
- 64. Transverse dimension ofsmile: - broad smile … 1st molar may be shown at the commissures. - buccal corridors … improved by : 1- maxillary widening. 2- ,, advancement. [email protected]
- 65.
- 66. Alternative Solutions Partial andFull Dentures Crowns Bridges [email protected]
- 67. Biocompatibility of Material DesiredMechanical Surfaces Properties • Composition • High yield strength • Ion release • Modulus close to that of bone’s • Surface • Built-in margin of modifications safety: Changes in environment around implant [email protected]
- 68. Metallic Implant Surface Problem: Implant surface change with time due to oxidation, precipitation… Possible solutions: • Oxide layers ( minimize ion release) • Prosthetic component from noble alloys • Phase stabilizers other than Al & V (eg. Ti-13Nb- 13Zr, Ti-15Mo-2.8Nb ) • Surface Modifications [email protected]
- 69. Types of Implants Screw Implants (Left to Right: TPS screw, Ledermann screw, Branemark screw, ITI Bonefit screw) Cylinder Implants (Left to Right: IMZ, Integral, Frialit-1 step-cylinder, Frialit-2 step-cylinder) [email protected]
- 70. Procedure First Surgical Phase(Implant Placement) Under Local anesthetic the dentist places dental implants into the jaw bone with a very precise surgical procedure. The implant remains covered by gum tissue while fusing to the jaw bone. Second Surgical Phase (Implant Uncovery) After approximately six months of healing. Under local anesthetic, the implant root is exposed and a healing post is placed over top of it so that the gum tissue heals around the post. Prosthetic Phase (Teeth) Once the gums have healed, an implant crown is fabricated and screwed down to the implant. [email protected]
- 71. What Is ADental Implant? Dental implants are used to: Replace a missing tooth Replace multiple missing teeth Replace an edentulous arch [email protected]
- 72.
- 73. Implant vs ConventionalBridges vs. Removable Dentures • There is a clear benefit to receiving dental implants • Quality of life improves • Diet and nutrition are positively impacted • Positive impact on leisure activities • Disadvantage of cutting down perfectly healthy teeth [email protected]
- 74. Patient Friendly Procedures Patientswant: Fast procedures Minimally invasive procedures Long lasting results Good esthetics [email protected]
- 75. Doctor Friendly Procedures •Transition from 2-stage to 1-stage procedures • Immediate load implants • Less invasive dental implant therapy • Tilted implants, guided flapless surgery • Advances in ceramic materials create a shift from function to esthetics [email protected]
- 76. Concerns About Recommending DentalImplants for the Elderly Fact or Fiction… Longer healing time Inadequate osseointegration of implants Loss of implants due to inadequate oral hygiene Patient’s desire and expectations for dental implants may differ with age [email protected]
- 77. Patient’s Expectations • Increasedresistance to implant surgery - “I’m too old”. • Long-term edentulous patients may be more tolerant to ill-fitting conventional dentures. • Recommendations for implant-assisted restorations should occur early in edentulism. • Elderly patients may take a greater period of time to adapt to a new prosthesis. [email protected]
- 78. Success Rate ofImplant Placement • Success rate of implants in the healthy elderly population is the same as that of younger age groups. • Degree of osseointegration with healthy geriatric patients is comparable to that of the younger population. [email protected]
- 79. Mandibular Overdentures • Improvethe stability and retention of the denture. • Can be placed over tooth roots or over implants. • Tooth roots provide sensory feedback but can decay or lose support due to periodontal disease or fracture. • Both tooth roots or implants will help retain the bone in the mandibular ridge. [email protected]
- 80. Growing Need forSatisfactory Tooth Replacement • Tooth replacement with implant-supported or assisted dentures provides greater patient satisfaction with comfort and chewing. • Stability and retention of denture is improved. [email protected]
- 81. Risk Factors forDental Implant Success in the Elderly • Oral Hygiene • Xerostomia • Cardiovascular disease • Diabetes • Osteoporosis • Cancer Implant therapy should be considered as a medical model in the geriatric population. [email protected]
- 82. Lessened Manual Dexterityand Visual Acuity May Affect Oral Self Care Oral Hygiene Success rate may be comparable to younger age groups when… • Appropriate modifications of oral health aids are made. • When adequate instruction and recall intervals are maintained. • Less complicated designs of implant abutments are utilized. [email protected]
- 83. SURGICAL REQUIREMENTS Standardised surgicalprotocol Surgical environment Implant equipment - reusable - disposable/single use Fully evaluated and prepared patient Trained staff [email protected]
- 84.
- 85. STAINLESS STEEL • Guide drill • 2mm twist drill • Pilot drill • 3mm twist drill • Countersink [email protected]
- 86. TITANIUM • Tap • Implant •Coverscrew [email protected]
- 87.
- 88. SURGICAL • Aseptic technique •Gentleness • Precision [email protected]
- 89. SURGICAL PRELIMINARIES • Inductionof anaesthesia • Endotracheal intubation • Throat pack • Scrub and gown • Surgical preparation • Draping [email protected]
- 90. SURGICAL PROCEDURE •Local Anaesthetic • Try in stent • Tattoo • Surgical incision • Flap reflection • Flap retraction • Try in stent [email protected]
- 91. SURGICAL PROCEDURE •Smooth ridge • Use stent • Guide drill • Small twist drill • Pilot drill • Large twist drill • Depth guide [email protected]
- 92. SURGICAL PROCEDURE • Countersink • Fixture insertion • Cover screw • Debridement • Closure [email protected]
- 93. POSTOPERATIVE CARE • Haemostasis •Analgesia • Antibiotic regime • Chlorhexidine mouthwash • Suture removal • Temporary prosthesis [email protected]
- 94. SECOND STAGE • Soft tissue • Bone removal • Cover screw removal • Healing abutment • Replacement • Dressings [email protected]
- 95. KEY POINTS • Implantpositioning - bucco/lingual - axial - separation • Drill speeds - 2000rpm - 20rpm • Torque • Irrigation [email protected]
- 96. MAXILLARY IMPLANTS • Lackof well defined cortex • Poorer quality cancellous bone • Lack of bucco/lingual width • Reduced height of available bone • Proximity of anatomical structures- nose - antrum - incisive canal [email protected]
- 97.
- 98. COMPLICATIONS • Preoperative • Perioperative • Postoperative • Transient • Persistent • Permanent • Soft tissue • Hard tissue [email protected]
- 99. SERIOUS COMPLICATIONS – Jawfracture – Haemorrhage – Ingestion – Inhalation – Neurological – Death [email protected]
- 100. COMPLICATIONS • Patient selection – Psyche – Anatomy – Systemic disease • Implant factors • Surgical • Prosthodontic • Errors in judgement • Deviation from established protocol [email protected]
- 101. ANATOMY • Unsuitable morphologically • Reduced bone density • Reduced bone volume • Attached tissue • Nerve position [email protected]
- 102. PREVENTION OF NERVEDAMAGE • CT • Bone density measurement • Drill sleeves • Discretion is better part of valour [email protected]
- 103. COMPLICATIONS Peroperative –Failure to obtain anaesthesia – Haemorrhage – Stuck implant – Loose implant – Lost implant [email protected]
- 104. SURGICAL FAILURE • Poor planning • Poor surgical technique • Lack of precision • Thermal injury • Faulty placement • Damage to adjacent structures [email protected]
- 105. SURGICAL • Haemorrhage • Stuck implant • Loose implant • Lost implant [email protected]
- 106. COMPLICATIONS • Wound dehiscence • Infection • Mucosal perforation • Fistula formation • Anatomical - antral - nasal - neurological [email protected]
- 107. STAGE ONE SURGERY • Failure to obtain anaesthesia • Faulty placement • Anatomical • Surgical [email protected]
- 108. SURGICAL • Stripped bone threads • Exposed implant threads • Fractured drill • Sheared implant hex • Excessive countersink • Eccentric drill [email protected]
- 109. COMPLICATIONS Second stage – Loose implant – Excess bone coverage – Exposed threads – Coverscrew problems [email protected]
- 110. STAGE TWO SURGERY • Wrong abutment length • Faulty abutment seating • Retained sutures • Gingival hyperplasia • Mobile tissue • Destroyed cover screw hex • Failure of integration [email protected]
- 111. FAULTY PLACEMENT • Labial / buccal • Lingual • Too close • Straight line in mandibular anteriors • Angulation • Divergence • Correct by use of a surgical template [email protected]
- 112. POSTOPERATIVE • Fascial space infections • Haematoma • Jaw fracture • Sinusitis • Wound dehiscence [email protected]
- 113. WOUND DEHISCENCE • Poor flap design • Poor surgical technique • Poor repair • Poor tissue quality • Previous surgery • Underlying medical condition • Superficial implant placement [email protected]
- 114. PERSISTENT • Neurological damage • Aesthetics • Speech • Function • Psychological [email protected]
- 115. PROSTHODONTIC • Avoid premature loading • Passive fit • Good design • Good oral hygiene • Loss of integration • Soft tissue problems • Oral hygiene and maintenance • Retrievable v cemented [email protected]
- 116. COMPONENT FAILURE • Fractured fixture • Fractured abutment screw • Fractured punch blade • Fractured screw driver tip • Fractured castings [email protected]
- 117. MANAGEMENT OF FAILURE • Failing implants FAIL • Removal • Abandon • Alternative site • Larger diameter • Replacement after healing [email protected]
- 118.
- 119.
- 120.
- 121.
- 122. Bone graft forimplant dentistry [email protected]
- 123. Diagnosis and TreatmentPlanning For Bone Augmentation Radiographic Examination • Panoramic radiograph • 20 to 30% distortion/magnification of the anatomic structures • Buccal to lingual width will not be appreciated • Alveolar bone height, adjacent teeth and anatomic structure
- 127.
- 128.
- 129.
- 130.
- 131. Factors that impacton fit: atrophy 1. Atrophy a. Decreasing bone b. Increasing soft tissue 1 3 2 4
- 132. Factors that impacton fit: atrophy 1. Atrophy a. Decreasing bone b. Increasing soft tissue
- 133. Factors that impacton fit: atrophy 1. Atrophy a. Decreasing bone b. Increasing soft tissue
- 134. Diagnosis and TreatmentPlanning For Bone Augmentation Clinical Examination • Minimal obtain 1 to 2mm of attached gingiva • Cross section of the alveolar depicting periodontal probe placement for “sounding the bone”. • To determine bone width • Cutting the study model in the exact vertical location
- 135. To Determine BoneWidth Harry Dym, Orrett E. Ogle: Atlas of Minor Oral Surgery. W.B. Saunders company. 2001
- 136.
- 137.
- 138. GRAFTING Autogenous - Local symphysis third molar angle tuberosity - Distant rib iliac crest tibia calvarial Allogenic - frozen - freeze dried - demineralized [email protected]
- 139. BIOMATERIALS - methyl methacrylate -silicone - proplast - teflon - calcium phosphates - plaster of paris - tricalcium phosphate - hydroxyapatite - goretex [email protected]
- 140. GRAFTS • Autogenous bone •Freeze dried bone • Synthetic biomaterials [email protected]
- 141. FREEZE DRIED BONE • Commercial preparation • Multiple donors • Screened for HIV, Hep B and C • Sterilised by irradiation • Risk of prion borne disease [email protected]
- 142. CALCIUM PHOSPHATES • Plasterof paris • Tricalcium phosphate • Hydroxyapatite [email protected]
- 143. INDICATIONS FOR GRAFTING • Anterior maxilla • Posterior maxilla • Anterior mandible • Posterior mandible • After resection • Post traumatic [email protected]
- 144. TECHNIQUES • Cortico-cancellous blocks • Trephined core • Sinus Lift • Vascularised bone flap [email protected]
- 145.
- 146. Sinus floor elevationtechnique 1- Internal 2-External [email protected]
- 147. Surgical Solutions toAnatomical Limitations Onlay Bone Graft Sinus Lift [email protected]
- 148. Radiological/Imaging Studies • Periapical radiographs • Panoramic radiograph • Site specific tomograms • CAT scan (Denta-scan, cone beam CT) [email protected]
- 149.
- 150. Anatomic Limitations Buccal Plate 0.5mm Lingual Plate 1.0 mm Maxillary Sinus 1.0 mm Nasal Cavity 1.0mm Incisive canal Avoid Interimplant distance 1-1.5mm Inferior alveolar canal 2.0mm Mental nerve 5mm from foramen Inferior border 1 mm Adjacent to natural tooth 0.5mm [email protected]
- 151. Types of BoneGrafts • Autograft – A graft taken from on anatomic location and placed in another location in the same individual(e.g., iliac crest) • Allograft – A graft taken from a cadever treated wit certain sterilization and antiantigenic procedures and placed into a living host • Alloplast – A chemically derived nonanimal material • Xenograft – A graft taken from a nonhuman host for implantation into a human host
- 152. Biology of BoneGrafts • Phase I – Osteogenesis: Immediate proliferation of transplanted osteocytes and subsequent formation of osteoid(immature bone) • Phase II – Osteoinduction: inducement of mesenchymal cells to produce bone(BMP) – Osteoconduction: framework or scaffold for the formation of new bone tissue
- 153. Autogenous Bone Graft •“Gold standard” – Standard by which other materials are judged • May provide osteoconduction, osteoinduction and osteogenesis • Drawbacks – Limited supply – Donor site morbidity
- 154. Autogenous Bone Grafts • Cancellous • Cortical • Free vascular transfers • Bone marrow aspirate
- 155. Cancellous Bone Grafts •Three dimensional scaffold (osteoconductive) • Osteocytes and stem cells (osteogenic) • A small quantity of growth factors (osteoinductive) • Little initial structural support • Can gain support quickly as bone is formed
- 156. Cortical Bone Grafts •Less biologically active than cancellous bone – Less porous, less surface area, less cellular matrix – Prologed time to revascularizarion • Provides more structural support – Can be used to span defects • Vascularized cortical grafts – Better structural support due to earlier incorporation – Also osteogenic, osteoinductive • Transported periosteum
- 157. Bone Marrow Aspirate •Osteogenic – Mesenchymal stem cells (osteoprogenitor cells) exist in a 1:50,000 ratio to nucleated cells in marrow aspirate – Numbers decrease with advancing age – Can be used in combination with an osteoconductive matrix
- 158. Autograft Harvest • Cancellous – Iliac crest (most common) • Anterior- taken from gluteus medius pillar • Posterior- taken from posterior ilium near SI joint – Metaphyseal bone • May offer local source for graft harvest – Greater trochanter, distal femur, proximal or distal tibia, calcaneus, olecranon, distal radius, proximal humerus
- 159. Autograft Harvest • Cancellousharvest technique – Cortical window made with osteotomes • Cancellous bone harvested with gouge or currette – Can be done with trephine instrument • Circular drills for dowel harvest • Commercially available trephines or “harvesters” • Can be a percutaneus procedure
- 160. Autograft Harvest • Cortical – Fibula common donor • Avoid distal fibula to protect ankle function • Preserve head to keep LCL, hamstrings intact – Iliac crest • Cortical or tricortical pieces can be harvested in shape to fill defect
- 161. Bone Allografts • Cancellousor cortical – Plentiful supply – Limited infection risk (varies based on processing method) – Provide osteoconductive scaffold – May provide structural support
- 162. Bone Allografts • Availablein various forms – Processing methods may vary between companies / agencies • Fresh • Fresh Frozen • Freeze Dried
- 163. Bone Allografts • Fresh – Highly antigenic – Limited time to test for immunogenicityor diseases – Use limited to joint replacement using shape matched osteochondral allografts
- 164. Bone Allografts • Freshfrozen – Less antigenic – Time to test for diseases – Strictly regulated by FDA – Preserves biomechanical properties • Good for structural grafts
- 165. Bone Allografts • Freeze-dried – Even less antigenic – Time to test for diseases – Strictly regulated by FDA – Can be stored at room temperature up – to 5 years – Mechanical properties degrade
- 166. Bone Graft Substitutes •Mechanical properties vary widely – Dependant on composition • Calcium phosphate cement has highest compressive strength • Cancellous bone compressive strength is relatively low • Many substitutes have compressive strengths similar to cancellous bone • All designed to be used with internal fixation
- 167. Grafting of theExtraction Socket • The teeth are extracted atraumatically preserving the buccal bone. • All granulation tissue is excised with the use of a surgical curette or a Rongeur.
- 168. Bone Morphogenetic Proteins •Produced by recombinant technology • Two most extensively studied and commercially available – BMP-2 (Infuse) Medtronics – BMP-7 (OP-1) Stryker Biotech
- 174. Harvesting Techniques III Cortical Onlay Bone Graft • Inadequate buccal to lingual/palatal width • Autogenous bone: donor sites-mandibular symphysis, mandibular ramus, calvarium or iliac crest • Allografts: demineralized freeze dried bone allograft blocks, freeze-dried blocks, and/or particles
- 175. Interpositional Ridge Graft •The approximate depth of the osteotomy should be 1cm. • A bibevel chisel is used to gently outfracture the buccal plate and allow enough width for the proposed implant • Split ridge technique
- 176.
- 177. Contemprary Oral & maxillofacial surgery Chapter 13 [email protected]
- 178. Thank you • Youcan get it form • http://www.slideshare.net/islamkassem