BASIC PRINCIPLES AND PRACTICE OF ORAL IMPLANTOLOGY AND OSSEOINTEGRATION

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OSSEOINTEGRATION
Definition

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OSSEOINTEGRATION
A direct structural and functional connection between ordered living bone and the surface of a load carrying implant P-I Branemark

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OSSEOINTEGRATION
Relies on an understanding of:of: Tissue healing and repair  Tissue remodelling  Soft tissues  Hard tissues  Effects of forces in all vectors  Immune response to the insertion of foreign bodies

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HISTORY
Century 17 20 Dental transplantation Subperiosteal Transosteal Vitreous carbon Blade Osseointegrated
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RESEARCH BASE
19521952-1960 19601960-1968 1965 19651965Vital microscopy Repair and regeneration of bone and marrow First jaw implant Clinical research
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SUCCESS
  

Rates Criteria Research reports

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HARVARD SUCCESS CRITERIA

The dental implant must provide functional service for 5 years in 75% of cases

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SUBJECTIVE CRITERIA
   

Adequate function Absence of discomfort Improved aesthetics Improved emotional and psychological wellbeing

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OBJECTIVE CRITERIA


Bone loss no greater than 33% of vertical length of implant Good occlusal balance and vertical dimension Gingival inflammation amenable to treatment Mobility of less than 1mm. in any direction Absence of symptoms of infection Absence of damage to surrounding structure Healthy connective tissues
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SUCCESS RATES
Subperiosteal Staple Vitreous carbon Blade Osseointegrated % 39 - 90 95 50 65 - 90 80 - 100

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BRANEMARK SYSTEM
    

Development Integrated Design Quality Control Precision Reliability

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ALTERNATIVE TECHNOLOGY
    

IMZ ITI 3M Corevent Apatite coated

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INDICATIONS FOR TREATMENT

Factors precluding wear of a removable prosthesis  Poor anatomy for denture support  Poor oral muscular coordination  Poor mucosal tissue tolerance  Parafunctional habits  Unrealistic expectations  Hyperactive gag reflex  Psychological inability to wear  Unfavourable number and location of abutments  Single tooth loss

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INDICATIONS
  

Fully edentulous Partially edentulous Single tooth

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INDICATIONS FULLY EDENTULOUS

  

Poor retention Functional disturbances Psychological disturbances

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MEDICAL EVALUATION
     

Cardiovascular Respiratory Renal Musculoskeletal Neurological Endocrine

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SPECIFIC MEDICAL CONDITIONS

   

 

Diabetes Coronary artery disease Alcoholism Drug therapy - anticoagulants - anti epileptics - antidepressants - others Osteoporosis Smoking

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PSYCHE


  

Perception of outcome  hypercritical  demanding  unrealistic expectation Time and expense Aesthetics Maintenance
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DENTAL EVALUATION
Assessment of overall oral health Prior to implant therapy, completion of:of: Oral Surgery  Periodontal therapy  Endodontics Temporisation of restorative dentistry Oral hygiene controlled and maintained
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RADIOLOGY
   

OPG Lateral Cephalogram Periapicals CT Scan - axial - coronal - 3D reconstruction - Dentascan MR

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DIAGNOSIS
  

Bone Quantity Bone Quality Associated structures - inferior alveolar nerve - mental nerve - maxillary antrum - nasal floor - incisive canal Pathology - retained dental remnants - periapical pathology - cysts - other pathology AS089522.ppt

ALVEOLAR FORM
A Good alveolar ridge form B Moderate residual ridge form C Advanced resorbtion / Basal bone only D Basal bone resorbtion E Extreme resorbtion

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BONE QUALITY
1 2 3 4 Mainly cortical plate compact bone Thick compact bone with a dense trabecular core Thin cortical plate with dense trabecular core Thin cortical plate with low density trabecular core
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BONE QUALITY

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ANATOMY
     

Mental nerve Inferior alveolar nerve Nasal cavity Maxillary antrum Incisive canal Soft tissues

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SURGICAL REQUIREMENTS
  

Standardised surgical protocol Surgical environment Implant equipment - reusable - disposable/single use

 

Fully evaluated and prepared patient Trained staff

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EQUIPMENT
FIRST STAGE

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STAINLESS STEEL
    

Guide drill 2mm twist drill Pilot drill 3mm twist drill Countersink

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TITANIUM
  

Tap Implant Coverscrew

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ANAESTHESIA
  

General Local Sedation

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SURGICAL
  

Aseptic technique Gentleness Precision

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SURGICAL PRELIMINARIES
     

Induction of anaesthesia Endotracheal intubation Throat pack Scrub and gown Surgical preparation Draping
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SURGICAL PROCEDURE
      

Local Anaesthetic Try in stent Tattoo Surgical incision Flap reflection Flap retraction Try in stent
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SURGICAL PROCEDURE
      

Smooth ridge Use stent Guide drill Small twist drill Pilot drill Large twist drill Depth guide
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SURGICAL PROCEDURE
    

Countersink Fixture insertion Cover screw Debridement Closure

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POSTOPERATIVE CARE
     

Haemostasis Analgesia Antibiotic regime Chlorhexidine mouthwash Suture removal Temporary prosthesis
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SECOND STAGE
     

Soft tissue Bone removal Cover screw removal Healing abutment Replacement Dressings

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KEY POINTS


Implant positioning

Drill speeds Torque Irrigation

- bucco/lingual - axial - separation - 2000rpm - 20rpm

 

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MAXILLARY IMPLANTS
    

Lack of 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
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TECHNIQUE MODIFICATIONS
  

Countersinking Self tapping implants Wide implants

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COMPLICATIONS WITH OSSEOINTEGRATED IMPLANTS

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COMPLICATIONS
       

Preoperative Perioperative Postoperative Transient Persistent Permanent Soft tissue Hard tissue
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SERIOUS COMPLICATIONS
     

Jaw fracture Haemorrhage Ingestion Inhalation Neurological Death

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COMPLICATIONS


Patient selection
  

Psyche Anatomy Systemic disease

    

Implant factors Surgical Prosthodontic Errors in judgement Deviation from established protocol
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ANATOMY
    

Unsuitable morphologically Reduced bone density Reduced bone volume Attached tissue Nerve position

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PREVENTION OF NERVE DAMAGE

   

CT Bone density measurement Drill sleeves Discretion is better part of valour

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COMPLICATIONS
Peroperative
    

Failure to obtain anaesthesia Haemorrhage Stuck implant Loose implant Lost implant
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SURGICAL FAILURE
     

Poor planning Poor surgical technique Lack of precision Thermal injury Faulty placement Damage to adjacent structures

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SURGICAL
   

Haemorrhage Stuck implant Loose implant Lost implant

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COMPLICATIONS
    

Wound dehiscence Infection Mucosal perforation Fistula formation Anatomical - antral - nasal - neurological
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STAGE ONE SURGERY

   

Failure to obtain anaesthesia Faulty placement Anatomical Surgical

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SURGICAL
     

Stripped bone threads Exposed implant threads Fractured drill Sheared implant hex Excessive countersink Eccentric drill

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COMPLICATIONS
Second stage
   

Loose implant Excess bone coverage Exposed threads Coverscrew problems

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STAGE TWO SURGERY

      

Wrong abutment length Faulty abutment seating Retained sutures Gingival hyperplasia Mobile tissue Destroyed cover screw hex Failure of integration
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FAULTY PLACEMENT
      

Labial / buccal Lingual Too close Straight line in mandibular anteriors Angulation Divergence Correct by use of a surgical template
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POSTOPERATIVE
    

Fascial space infections Haematoma Jaw fracture Sinusitis Wound dehiscence

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WOUND DEHISCENCE
      

Poor flap design Poor surgical technique Poor repair Poor tissue quality Previous surgery Underlying medical condition Superficial implant placement
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PERSISTENT
    

Neurological damage Aesthetics Speech Function Psychological

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COMPLICATIONS
Long term
      

Anatomical Neurological Deintegration Progressive thread exposure Gingivitis Hyperplastic tissue Fractured Implant
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PROSTHODONTIC
       

Avoid premature loading Passive fit Good design Good oral hygiene Loss of integration Soft tissue problems Oral hygiene and maintenance Retrievable v cemented
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COMPONENT FAILURE
    

Fractured fixture Fractured abutment screw Fractured punch blade Fractured screw driver tip Fractured castings

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MANAGEMENT OF FAILURE
     

Failing implants FAIL Removal Abandon Alternative site Larger diameter Replacement after healing

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GRAFTING TECHNIQUES

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GRAFTING
Autogenous - Local symphysis third molar angle tuberosity - Distant rib iliac crest tibia calvarial - frozen - freeze dried - demineralized

Allogenic

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BIOMATERIALS
- methyl methacrylate - silicone - proplast - teflon - calcium phosphates - plaster of paris - tricalcium phosphate - hydroxyapatite - goretex

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GRAFTS
  

Autogenous bone Freeze dried bone Synthetic biomaterials

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FREEZE DRIED BONE

     

Commercial preparation Multiple donors Screened for HIV, Hep B and C Sterilised by irradiation Risk of prion borne disease Not licensed in Australia

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CALCIUM PHOSPHATES
  

Plaster of paris Tricalcium phosphate Hydroxyapatite

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INDICATIONS FOR GRAFTING

     

Anterior maxilla Posterior maxilla Anterior mandible Posterior mandible After resection Post traumatic

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TECHNIQUES
   

CorticoCortico-cancellous blocks Trephined core Sinus Lift Vascularised bone flap

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