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Treatment concepts
?
Patient driven concept ? Surgeon driven concept ? Prosthodontist driven concept ?
A proper planning is important for obtaining an acceptable final result Complete treatment plan needs consultation from both surgeon and prosthodontist Surgeon should also has the knowledge of prosthodontic planning
Osteointegration
Functional ankylosis
Bone regeneration
Sequence of bone
regeneration
-
Immediate (Inflammatory)
response Bone formation Bone remodaling
Bone regeneration
Bone regeneration
PDGF
TGF-
VEGF
Bone regeneration
Bone regeneration
Bone marrows
Circulation
Periosteum
Bone regeneration
Anatomical fundamentals
Haematoma Vessel- and collagen formation Mineralisation of collagen Bone maturation Remodelling
REM: Aggregation auf der Kollagenmatrix
osteocyte
cement layer
implant
1. 2.
early osteopontin expression at initial cement layer formation collagen matrix on the cement layer is mineralised by alc. phosph. and BSP
3.
4.
Precise fitting
Maximum direct bone-implant contact Press-fitting phenomenon Cause local overload Overload -> microcrack, fissure Bone becomes avascular and necrotic in early stage In second stage - bore hole replace by lamella bone in 3 months In 15 months - 60-70% living bone contact
Provide less primary stability Only 20-25% density compare to compact bone Vascular rich / osteoblast rich Divided into two area 1. Trabeculae contact 2. Marrow contact
3. Immediate function
Possibilities of loading
Immediate implantation + immediate loading Immediate implantation + shortened healing phase
functional loading
* Schliephake; Konzepte zur Verkrzung der Behandlungsdauer. Implantologie; 9/4: 357-372 (2001)
implant retention
biological
mechanical
Bone
If the temperature of the bone exceeds 47 C for 1 minute, bone resorption and fat cell degeneration occurs
Eriksson and Albrektsson 1983
Dense bone
: 1500 rpm
Misch 1993
Bone tapping
Recommended for cases in which the bone is dense, compact and poorly vascularized (Type I or II) Not recommended for type III or IV
Inadequate irrigation
Torquing or drilling at high speed
Collins and Collins 1998
Implant insertion
Principle
-
Primary stability is required No excessive force For screw-implant : 10-20 rpm 20-50 Ncm
Anatomical limitation :
1. Inferior alveolar nerve 2. Maxillary sinus 3. Bone mass
Anchorage needed
Drill Tip
H L= -c-s M
15 L= 22=8 5/4
Prediction for proper direction of fixture : There are many way to determine
1. Surgical stent
2. Guide pin
3. Occlusion 4. Teeth adjacent to the space 5. Intraop. X-Ray
Correct prosthetic-implant
angulation
Stage II procedure
important point
Abutment selection
Bone
Long-term success of dental implants appears to be highly dependent on both quality and quantity of the available bone
Jaffin Ra, Berman CL 1991
Jaw shape and bone quality must be regarded as the most influential factors affecting implant survival
Friberg et al 1991
Bone Quanlity
The entire mandible/maxilla is composed of homogeneous compact bone. A thick layer of compact bone surrounds a core of dense trabecular bone. A thin layer of cortical bone surrounds a core of low-density trabecular bone of favorable
strength.
4 A thin layer of cortical bone surrounds a core of low-density trabecular bone.
Bone Quantity
Most of the alveolar ridge is present. Moderate ridge resorption has occured. Advanced alveolar ridge resorption has occurred, and only nasal bone remains. Some resorption of the basal bone has taken place. Extreme resorption of the basal bone has taken place.
Lekholm U, Zarb GA 1985
Maxilla
-
Healthy
Madible
-
Healthy
Bone resorption
Change of angle class Change of intermaxillary distance
Defect
Bone?
Soft tissue?
Guided bone regeneration Bone condensing, spreading, splitting Autogenous bone graft Bone substitute Sinus lift Nerve transpositioning Interpositional bone graft Microvascular free flap
Osteopromotion system Promote osseous healing in defect Exclude non-osteogenic soft tissue from defect healing
As soft tissue support and prevention for collapse of space Creation of clot space provide osteogenic cells migration Protection of granulation tissue Promote vascular network formation
Collapse
Bone condensing
Principle
-
Nonablative implant bed preparation Condensation of spongiosa at boneimplant contact Alveolar ridge extension horizontally and vertically To improve primary stability in D3, D4 bone density Thin alveolar ridge (>3 mm) Closed sinus lift
Indication
-
Bone condensing
Procedures
-
Lindemann-bur
Bone spreading
Principle
-
Nonablative implant bed preparation as well as alveolar ridge extension Condensation of spongiosa at boneimplant contact Thin alveolar ridge (at least 3 mm) Bone density D3 and D4
Indication
-
Bone spreading
Instruments
-
Bone spreading
Precedures
-
Parapapilla incision
Crestal incision
Fine Lindemann-bur, Disc
Cortical osteotomy
A width of 2-4 mm
Lindemann-bur
Bone spreading
Procedures
-
Use the instrument step-by-step Apply through pilot hole until the expected depth Rotation and anteroposterior extension
Stop the manuveurs if the alveolar ridge width is adequate for implant placement
Last implant preparation bur
Pre / Intraimplantation osteotomy of alveolar ridge bucco-lingually Mobilisation of segments in transverse direction Atrophic alveolar ridge width (2 mm) Adequate bone height
Indication
-
Diamond disc
Chisels Bone condenser set Bone substitues (if need)
Procedures
-
Diamond disc Distance from neighbouring teeth ~ 1 mm Osteotomy at midcrestal bone and mesial/distal
Bone augmentation
3 mm. 5 mm.
Bone graft
Burchardt 1983,Hirsch and Ericsson 1991,Lundgren et al 1996, Raghoebar et al 1993,Wood and Moore 1988
Disadvantages
Bone graft
Using bone substitutes avoids or reduces problems associated with autogenous bone graft harvesting
The ability to produce bone by cellular proliferation from viable transplanted osteoblasts or by osteoconduction of cells along the grafts surface The ability to produce bone by osteoinduction of recruited mesenchymal cells Remodeling of the initially formed bone into mature lamellar bone Maintainance of the mature bone over time without loss through function The ability to stabilize implants when placed simultaneously with the graft Low infection rate Ease of availability Low antigenicity High level of reliability
Bone graft
Autogenous bone DFDBA (Lifenet) Calcium carbonate (Biocoral) Bioactive glass (Bioglass) Polymer of polylactic & polyglycolic acids (Fisiograft) Bovine-derived bone and peptide (Pepgen P-15) Calcium sulfate (Surgiplaster sinus) Bovine deproteinized bone (Bio-Oss) Hydroxyapatite (Fingranule)
Scarano et al 2006
Bone graft
Scarano et al 2006
100 %
New bone
Maxillary sinus
Maxillary sinus is a pyramidshaped cavity with its base adjacent to the nasal wall and apex pointing to the Zygoma Adult sinus
2.5 3.5 cm. wide 3.6 4.5 cm. tall 3.8 4.5 cm. deep Volume 12-15 cm3
History
Maxillary sinus graft was first described by Tatum at Alabama implant conference in 1976
First published by Boyne & James in 1980 Osteotome technique was described by Summers in 1994
Sinus lift
Principle
- Elevation of Schneiderian membrane to recontour the sinus in the cranial direction and followed by bone graft
Indication
-
Sinus lift
Procedures
-
Bone augmentation
93.1 %
2-Stage implantation
20
40
60
80
100
Number of Implants
201 73 167 467 67 181 ? 120 160 57 55 204 392 207 161
Implantation
sec sim sec sim sim/ sec sim sec sim/ sec sim sim sim
F/U
Blomqvist Block Fugazzotto Khoury Kbler Lekholm Lorenzetti Olson Peleg (a) Peleg (b) Peleg Raghoebar Raghoebar Smedberg v. d. Bergh
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%
1999
1999 1998 1999 2001 2001 1998 2000 2000 1998 1999 1998
sec
sec sim ? sim sec sec sim sim/ sec
32
12-124 36 12-72 12 12 70 24 30
Wannfors
Wannfors Watzek Wiltfang Zitzmann
20
20 7 53 30
?
? 14 63 30
76
74 53 132 79
Total
994
1240
2853
93,59 %
Nerve transpositioning
Principle
-
Transposition of inferior alveolar nerve to achieve primary stability without bone augmentation Inadequate alveolar height of posterior mandible Optimal interarch space Compression of mental nerve
Indication
-
Distraction osteogenesis
Principle
-
Controlled, gradual vital bone regeneration between osteotmy segments Increase alveolar ridge height without bone graft Vertical alveolar atrophy Adequate bone width Open bite
Indication
-
Soft diet
Daily gentle cleansing
Papilla regeneration
Membrane
Flap design
Principle
Preserve blood supply Preserve the topographic of alveolar ridge and mucobuccal fold Identification of important anatomic structures Provide access for implant instrumentation and use of surgical guides Provide access for harvesting of local bone Provide for closure away from implant or tissue augmentation sites Minimize bacterial contamination Facilitate circumferential closure around permucosal implant structures
Flap design
Papilla reflection
Indication
-
Parapapilla incision
Indication
-
Indication
-
Indication
-
Esthetic implant site Access of the buccal aspect is unnecessary No need of augmentation To prevent scarring and soft tisssue recession
(Mid)crestal incision
Curvilinear incision
Indication
- As trapezoidal flap
Advantages
-
Incorporation with a greater volume of mucosal tissue Improving elasticity Flexible for flap adaptation or transposition Good esthetic results Allow for correction of hard and soft tissue defects simultaneous with implatation Cutback incision reduces the need of periosteal releasing incision
Curvilinear incision
Skin graft
VIP-CT flap
Papilla regeneration
Membrane
1 week
2 weeks