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Speed Implants

Categories: General info | 2011 | by Administrator | no comments

Speed implants is a term given to dental implants that take no time at all. Instead of the long and often tedious waiting process associated with staged implants that take anywhere from a few months to almost half a year. Speed implants gives you a missing tooth instantly but not without risk. First of all, the process of waiting for osseointegration (the process by which the implant is anchored onto by the surrounding tissue and bone making it more stable) is still the most preferred method for it allows ample time to stabilize the base for the implant. Speeding up the process leaves you with an implant that has a higher possibility of failure for it has no firm base to hold on to. Speed implants are quite amiable to most for it allows you a quick fix for an embarrassing situation. Say you have to get married and want that perfect smile, then it would surely be one to consider but be sure to ask for your dentists opinion on the matter so you get the whole picture.

A dental implant is used for prosthetic dentistry to replace a missing tooth. Unlike ordinary dentures that are held in place by your gums, a dental implant replaces the entire tooth, including the root that keeps the tooths crown in place. A metal cylinder made of titanium is incorporated into the jaw bone, and provides support to the artificial crown. New bone regenerates and eventually grows around the implant, making it a permanent part of your jaw.
A dental implant is used for prosthetic dentistry to replace a missing tooth. Unlike ordinary dentures that are held in place by your gums, a dental implant replaces the entire tooth, including the root that keeps the tooths crown in place. A metal cylinder made of titanium is incorporated into the jaw bone, and provides support to the artificial crown. New bone regenerates and eventually grows around the

Are you a candidate for dental implant?

You may be a candidate for dental implant if you are no longer a growing child, and you have one or more of the following conditions: Missing one or more teeth Have unusually wide spaces in between teeth Have trouble eating, chewing or speaking properly Use dentures that cause sore spots when chewing, or is unwilling to use dentures Have problems with existing crowns or bridges Teeth holding your bridge or crown are moving or loosening

There are different types of dental implants suited to different patients. The implants used depends on the size and shape of the jaw, in particular the amount and quality of the bone. Most dental implants are made of titanium and placed directly into the jawbone. All types of implants can be used to replace single teeth or to support a full dental bridge, replacing a full set of teeth.
Root Form Dental Implants

Root form dental implants are the most common, also known as Endosteal or Endosseous implants. This type of implant is ideal for patients with a wide, deep and healthy jawbone. Their shape resembles the natural tooth root. However, if there is not enough bone to place these implants a bone graft is a possible solution. These dental implants can be placed using conventional dental implant surgery where the gum is raised to expose the bone for implant placement, or using a guided surgery technique.

Plate form dental implants

Plate form implants are long and flat, they are used when the jaw is very narrow and bone grafting is not appropriate. These implants are placed using conventional surgery usually in two stages with a gap between procedures for healing.
Subperiosteal Dental Implants

A subperiosteal implant is custom made and placed beneath the gums on top of the bone, used if there is not enough bone for a root form or plate form implant. It is designed to suit the individual jaw of the patient. Subperiosteal implants are not usually recommended as they have a higher failure rate than other types and cost more. As this implant is made to suit the patients individual anatomy, it is designed and produced using three-dimensional models of the jaws either made from a CT scan or a dental impression of the patients jaws.
Mini dental implants

Mini dental implants are as their name suggests mini versions of root form implants. Originally created to as temporary implants, they are now often used as a permanent implant solution, especially for smaller teeth. Mini implants can be used if there is not enough bone for normal implants and a bone graft is not appropriate. The mini implant is a very cost-effective solution. Although it does not easily fuse with the bone, they are a durable, long lasting solution for many patients. Mini implants can also be used to support dentures.
Zygomatic Dental Implants

When there is not enough bone for ordinary implants, zygomatic implants can be used in the upper jaw. This is a very specialist procedure and is not available in all dental practices. Zygomatic implants significantly longer than ordinary dental implants and anchor to the cheekbone, or zygomatic arch. They can be used as an alternative to complex bone grafting and make it possible to carry out surgery a single stage. A CT scan is required to assess the amount of bone in the upper jaw to allow your dentist to plan implant placement without carrying out invasive surgery. Usually, two zygomatic implants are placed as well as 2-4 root form dental implants. When there is even less bone, four zygomatic implants are used. Guided surgery can sometimes be used to assist accurate placement.

Guided surgery

Guided surgery can also be used to place dental implants. This involves computeraided surgical planning based on CT scans of your jaw. The surgery is performed using a surgical drill guide to position the implants in the jaw. It is possible for this to be a single stage procedure and some patients undergo the surgery and tooth restoration in a single day i.e. they leave with a finished set of teeth.
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A dental implant is a "root" device, usually made of titanium, used in dentistry to support restorations that resemble a tooth or group of teeth to replace missing teeth. Virtually all dental implants placed today are root-form endosseous implants, i.e., they appear similar to an actual tooth root (and thus possess a "root-form") and are placed within the bone (endo- being the Greek prefix for "in" and osseous referring to "bone"). The bone of the jaw accepts and osseointegrates with the titanium post. Osseointegration refers to the fusion of the implant surface with the surrounding bone. Dental implants will fuse with bone, however they lack the periodontal ligament, so they will feel slightly different than natural teeth during chewing. Prior to the advent of root-form endosseous implants, most implants were either blade endosseous implants, in that the shape of the metal piece placed within the bone resembled a flat blade, or subperiosteal implants, in which a framework was constructed to lie upon and was attached with screws to the exposed bone of the jaws. Dental implants can be used to support a number of dental prostheses, including crowns, implant-supported bridges or dentures.[1] They can also be used as anchorage for orthodontic tooth movement. The use of dental implants permits undirectional tooth movement without reciprocal action.

A typical implant consists of a titanium screw (resembling a tooth root) with a roughened or smooth surface. The majority of dental implants are made out of commercially pure titanium, which is available in 4 grades depending upon the amount of carbon and iron contained.[10] More recently grade 5 titanium has increased in use. Grade 5 titanium, Titanium 6AL-4V, (signifying the Titanium alloy containing 6% Aluminium and 4% Vanadium alloy) is believed to offer similar osseointegration levels as commercially pure titanium. Ti- 6Al-4V alloy offers better tensile strength and fracture resistance. Today most implants are still made out of commercially pure titanium (grades 1 to 4) but some implant systems are fabricated out of the Ti-6Al-4V alloy.[11] Implant surfaces may be modified by plasma spraying, anodizing,[12] etching, or sandblasting to increase the surface area and osseointegration potential of the implant.

[edit] Training
There is no specialty recognized by the ADA for dental implants. Implant surgery may be performed as an outpatient under general anesthesia, oral conscious sedation, nitrous oxide sedation, intravenous sedation or under local anesthesia by trained and certified clinicians including general dentists, endodontists, oral surgeons, periodontists, and prosthodontists. The legal training requirements for dentists who carry out implant treatment differ from country to country. In the UK, implant dentistry is considered by the General Dental Council to be a postgraduate sphere of dentistry. In other words it is not sufficiently covered during the teaching of the university dental degree course and dentists wishing to practice in dental implantology legally need to undergo additional formal postgraduate training. The General Dental Council has published strict guidelines on the training required for a dentist to be able to place dental implants in general dental practice.[13] UK dentists need to complete a competency assessed postgraduate extended learning program before providing implant dentistry to patients. The degree to which both graduate and post-graduate dentists receive training in the surgical placement of implants varies from country to country,[14][15][16] but it seems likely that lack of formal training will lead to higher complication rates.[17] In the United States, several implant training courses are available through most major manufacturers. These hands-on courses emphasize treatment planning, case selection, implant placement protocol, restorative techniques, and marketing strategies.

[edit] Surgical procedure

[edit] Surgical planning

Prior to commencement of surgery, careful and detailed planning is required to identify vital structures such as the inferior alveolar nerve or the sinus, as well as the shape and dimensions of the bone to properly orient the implants for the most predictable outcome. Two-dimensional radiographs, such as orthopantomographs or

periapicals are often taken prior to the surgery. Sometimes, a CT scan will also be obtained. Specialized 3D CAD/CAM computer programs may be used to plan the case. Whether CT-guided or manual, a 'stent' may sometimes be used to facilitate the placement of implants. A surgical stent is an acrylic wafer that fits over either the teeth, the bone surface or the mucosa (when all the teeth are missing) with pre-drilled holes to show the position and angle of the implants to be placed. The surgical stent may be produced using stereolithography following computerized planning of a case from the CT scan. CT guided surgery may double the cost compared to more commonly accepted approaches.
[edit] Basic procedure

In its most basic form, the placement of an implant requires a preparation into the bone using either hand osteotomes or precision drills with highly regulated speed[18] to prevent burning or pressure necrosis of the bone. After a variable amount of time to allow the bone to grow on to the surface of the implant (osseointegration), a crown or crowns can be placed on the implant. Unlike conventional dental implants, Mini dental implants may be loaded immediately and still have a high survival rate (94%).[19][20] The amount of time required to place an implant will vary depending on the experience of the practitioner, the quality and quantity of the bone and the difficulty of the individual situation.
[edit] Detail procedure

At edentulous (without teeth) jaw sites, a pilot hole is bored into the recipient bone, taking care to avoid the vital structures (in particular the inferior alveolar nerve or IAN and the mental foramen within the mandible). Drilling into jawbone usually occurs in several separate steps. The pilot hole is expanded by using progressively wider drills (typically between three and seven successive drilling steps, depending on implant width and length). Care is taken not to damage the osteoblast or bone cells by overheating. A cooling saline or water spray keeps the temperature of the bone to below 47 degrees Celsius (approximately 117 degrees Fahrenheit). The implant screw can be self-tapping, and is screwed into place at a precise torque so as not to overload the surrounding bone (overloaded bone can die, a condition called osteonecrosis, which may lead to failure of the implant to fully integrate or bond with the jawbone). Typically in most implant systems, the osteotomy or drilled hole is about 1mm deeper than the implant being placed, due to the shape of the drill tip. Surgeons must take the added length into consideration when drilling in the vicinity of vital structures.
[edit] Surgical incisions

Straumann guide pin in place to visualize positioning, angulation and depth prior to implant placement. Implant is being placed as a flapless procedure because it was clinically and radiographically evident that there is adequate bone in all dimensions.

Traditionally, an incision is made over the crest of the site where the implant is to be placed. This is referred to as a 'flap'. Some systems allow for 'flapless' surgery where a piece of mucosa is punched-out from over the implant site. Proponents of 'flapless' surgery believe that it decreases recovery time while its detractors believe it increases complication rates because the edge of bone cannot be visualized.[21][22] Because of these visualization problems flapless surgery is often carried out using a surgical guide constructed following computerized 3D planning of a pre-operative CT scan.
[edit] Healing time

The amount of time required for an implant to become osseointegrated is a hotly debated topic.[23] Consequently the amount of time that practitioners allow the implant to heal before placing a restoration on it varies widely. In general, practitioners allow 26 months for healing but preliminary studies show that early loading of implant may not increase early or long term complications.[24] If the implant is loaded too soon, it is possible that the implant may move which results in failure. For conventional implants, the subsequent time to heal, possibly graft, and eventually place a new implant may take up to eighteen months. For this reason many are reluctant to push the envelope for healing.
[edit] One-stage, two-stage surgery

When an implant is placed either a 'healing abutment', which comes through the mucosa, is placed or a 'cover screw' which is flush with the surface of the dental implant is placed. When a cover screw is placed the mucosa covers the implant while it integrates then a second surgery is completed to place the healing abutment. Two-stage surgery is sometimes chosen when a concurrent bone graft is placed or surgery on the mucosa may be required for esthetic reasons. Some implants are one piece so that no healing abutment is required. In carefully selected cases, patients can be implanted and restored in a single surgery, in a procedure labeled "Immediate Loading". In such cases a provisional prosthetic tooth or crown is shaped to avoid the force of the bite transferring to the implant while it integrates with the bone.
[edit] Surgical timing

There are different approaches to place dental implants after tooth extraction. The approaches are:
1. Immediate post-extraction implant placement. 2. Delayed immediate post-extraction implant placement (2 weeks to 3 months after extraction). 3. Late implantation (3 months or more after tooth extraction).

According to the timing of loading of dental implants, the procedure of loading could be classified into:
1. Immediate loading procedure. 2. Early loading (1 week to 12 weeks). 3. Delayed loading (over 3 months) [edit] Immediate placement

An increasingly common strategy to preserve bone and reduce treatment times includes the placement of a dental implant into a recent extraction site. In addition, immediate loading is becoming more common as success rates for this procedure are now acceptable. This can cut months off the treatment time and in some cases a prosthetic tooth can be attached to the implants at the same time as the surgery to place the dental implants. Because one of three implants requires a minimum addition of bone tissue, surgical techniques for underlying bone augmentation are currently under a large scale development.[25]

Most data suggests that when placed into single rooted tooth sites with healthy bone and mucosa around them, the success rates are comparable to that of delayed procedures with no additional complications.[26]
[edit] Use of CT scanning

CT scan of the lower jaw. This shows eight dental implants superimposed over the lower jaw in areas of maximum bone and four teeth that will be extracted.[27]

When computed tomography or, more specifically, cone beam computed tomography or CBCT (3D X-ray imaging) is used preoperatively to accurately pinpoint vital structures including the inferior alveolar canal, the mental foramen, and the maxillary sinus, the chances of complications might be reduced as is chairtime and number of visits.[28] Cone beam CT scanning, when compared to traditional medical CT scanning, utilizes less than 2% of the radiation, provides more accuracy in the area of interest, and is safer for the patient.[29] CBCT allows the surgeon to create a surgical guide, which allows the surgeon to accurately angle the implant into the ideal space.[30]

[edit] Complementary procedures

Sinus lifting is a common surgical intervention. A dentist or specialist with proper training such as an oral surgeon, periodontist, general dentist or prosthodontist, thickens the inadequate part of atrophic maxilla towards the sinus with the help of bone transplantation or bone expletive substance. This results in more volume for a better quality bone site for the implantation. Prudent clinicians who wish to avoid placement of implants into the sinus cavity pre-plan sinus lift surgery using the CBCT X-ray, as in the case of posterior mandibular implants discussed earlier. Bone grafting will be necessary in cases where there is a lack of adequate maxillary or mandibular bone in terms of front to back (lip to tongue) depth or thickness; top to bottom height; and left to right width. Sufficient bone is needed in three dimensions to securely integrate with the root-like implant. Improved bone heightwhich is very difficult to achieveis particularly important to assure ample anchorage of the implant's root-like shape because it has to support the mechanical stress of chewing, just like a natural tooth. Typically, implantologists try to place implants at least as deeply into bone as the crown or tooth will be above the bone. This is called a 1:1 crown to root ratio. This ratio establishes the target for bone grafting in most cases. If 1:1 or more cannot be achieved, the patient is usually advised that only a short implant can be placed and to not expect a long period of usability. A wide range of grafting materials and substances may be used during the process of bone grafting / bone replacement. They include the patient's own bone (autograft), which may be harvested from the hip (iliac crest) or from spare jawbone; processed bone from cadavers (allograft); bovine bone or coral (xenograft); or artificially produced bone-like substances (calcium sulfate with names like Regeneform; and hydroxyapatite or HA, which is the primary form of calcium found in bone). The HA is effective as a substrate for osteoblasts to grow on. Some implants are coated with HA for this reason, although the bone forming properties of many of these substances is a hotly debated topic in bone research groups. Alternatively the bone intended to support the implant can be split and widened with the implant placed between the two halves like a sandwich. This is referred to as a 'ridge split' procedure. Bone graft surgery has its own standard of care. In a typical procedure, the clinician creates a large flap of the gingiva or gum to fully expose the jawbone at the graft site, performs one or several types of block and onlay grafts in and on existing bone, then installs a membrane designed to repel unwanted infection-causing microbiota found in the oral cavity. Then the mucosa is carefully sutured over the site. Together with a course of systemic antibiotics and topical antibacterial mouth rinses, the graft site is allowed to heal (several months). The clinician typically takes a new radiograph to confirm graft success in width and height, and assumes that positive signs in these two dimensions safely predict success in the third dimension; depth. Where more precision is needed, usually when mandibular implants are being planned, a 3D or cone beam radiograph may be called for at this point to enable accurate measurement of bone and location of nerves and vital structures for proper treatment planning. The same radiographic data set can be employed for the preparation of computer-designed placement guides.

Correctly performed, a bone graft produces live vascular bone which is very much like natural jawbone and is therefore suitable as a foundation for implants.

[edit] Considerations

Chrome-cobalt disc with bridges and crowns for dental implants manufactured using WorkNC Dental CAD/CAM

For dental implant procedure to work, there must be enough bone in the jaw, and the bone has to be strong enough to hold and support the implant. If there is not enough bone, more may need to be added with a bone graft procedure discussed earlier. Sometimes, this procedure is called bone augmentation, or guided bone regeneration. Mini dental implants are particularly useful in the endentulous arch with minimal remaining bone facio-lingually.[31] In addition, natural teeth and supporting tissues near where the implant will be placed must be in good health. In all cases careful consideration must be given to the final functional aspects of the restoration, such as assessing the forces which will be placed on the implant. Implant loading from chewing and parafunction (abnormal grinding or clenching habits) can exceed the biomechanic tolerance of the implant bone interface and/or the titanium material itself, causing failure. This can be failure of the implant itself (fracture) or bone loss, a "melting" or resorption of the surrounding bone. The dentist must first determine what type of prosthesis will be fabricated. Only then can the specific implant requirements including number, length, diameter, and thread pattern be determined. In other words, the case must be reverse engineered by the restoring dentist prior to the surgery. If bone volume or density is inadequate, a bone graft procedure must be considered first. The restoring dentist may consult with the oral surgeon, periodontist, endodontist, or another trained general dentist to co-treat the patient. Usually, physical models or impressions of the patient's jawbones and teeth are made by the restorative dentist at the implant surgeons request, and are used as physical aids to treatment planning. If not supplied, the implant surgeon makes his own or relies upon advanced computer-assisted tomography or a cone beam CT scan to achieve the proper treatment plan. Computer simulation software based on CT scan data allows virtual implant surgical placement based on a barium impregnated prototype of the final prosthesis. This

predicts vital anatomy, bone quality, implant characteristics, the need for bone grafting, and maximizing the implant bone surface area for the treatment case creating a high level of predictability. Computer CAD/CAM milled or stereolithography based drill guides can be developed for the implant surgeon to facilitate proper implant placement based on the final prosthesis' occlusion and aesthetics. Treatment planning software can also be used to demonstrate "try-ins" to the patient on a computer screen. When options have been fully discussed between patient and surgeon, the same software can be used to produce precision drill guides. Specialized software applications such as 'SimPlant' (simulated implant) or 'NobelGuide' use the digital data from a patient's CBCT to build a treatment plan. A data set is then produced and sent to a lab for production of a precision in-mouth drilling guide.[32]

[edit] Success rates

Dental implant success is related to operator skill, quality and quantity of the bone available at the site, and the patient's oral hygiene. The consensus is that implants carry a success rate of around 95%[33] One of the most important factors that determine implant success is the achievement and maintenance of implant stability.[34] The stability is presented as an ISQ (Implant Stability Quotient) value. Other contributing factors to the success of dental implant placement, as with most surgical procedures, include the patient's overall general health and compliance with post-surgical care.

[edit] Failure
Failure of a dental implant is often related to the failure of the implant to osseointegrate correctly with the bone, or vice-versa. A dental implant is considered to be a failure if it is lost, mobile or shows peri-implant (around the implant) bone loss of greater than 1.0 mm in the first year and greater than 0.2 mm a year after. Dental implants are not susceptible to dental caries but they can develop a condition called peri-implantitis. This is an inflammatory condition of the mucosa and/or bone around the implant which may result in bone loss and eventual loss of the implant. The condition is usually, but not always, associated with a chronic infection. Periimplantitis is more likely to occur in heavy smokers, patients with diabetes, patients with poor oral hygiene and cases where the mucosa around the implant is thin.[35] Currently there is no universal agreement on the best treatment for peri-implantitis. The condition and its causes is still poorly understood.[36] Risk of failure is increased in smokers. For this reason implants are frequently placed only after a patient has stopped smoking as the treatment is very expensive. More rarely, an implant may fail because of poor positioning at the time of surgery, or may be overloaded initially causing failure to integrate. If smoking and positioning problems exist prior to implant surgery, clinicians often advise patients that a bridge or partial denture rather than an implant may be a better solution.

Failure may also occur independently of the causes outlined above. Implants like any other object suffers from wear and tear. If the implant(s)in question are replacing commonly used teeth, then these may suffer from wear and tear and after years may crack and break up, although this is a very rare occurrence. The only way to minimize the risk of this happening is to visit your local dentist for regular reviews. In the majority of cases where an implant fails to integrate with the bone and is rejected by the body the cause is unknown. This may occur in around 5% of cases. To this day we still do not know why bone will integrate with titanium dental implants and why it does not reject the material as a 'foreign body'. Many theories have been postulated over the last five decades. A recent theory argues that rather than being an active biological tissue response, the integration of bone with an implant is the lack of a negative tissue response. In other words, for unknown reasons the usual response of the body to reject foreign objects implanted into it does not function correctly with titanium implants. It has further been postulated that an implant rejection occurs in patients whose bone tissues actually react as they naturally should with the 'foreign body' and reject the implant in the same manner that would occur with most other implanted materials.[37]

[edit] Contraindications
There are few absolute contraindications to implant dentistry. However, there are some systemic, behavioral, and anatomic considerations that should be assessed. Particularly for mandibular (lower jaw) implants, in the vicinity of the mental foramen (MF), there must be sufficient alveolar bone above the mandibular canal also called the inferior alveolar canal or IAC (which acts as the conduit for the neurovascular bundle carrying the inferior alveolar nerve or IAN). Failure to precisely locate the IAN and MF invites surgical insult by the drills and the implant itself. Such insult may cause irreparable damage to the nerve, often felt as a paresthesia (numbness) or dysesthesia (painful numbness) of the gum, lip and chin. This condition may persist for life and may be accompanied by unconscious drooling. Uncontrolled Type II diabetes is a significant relative contraindication as healing following any type of surgical procedure is delayed due to poor peripheral blood circulation. Anatomic considerations include the volume and height of bone available. Often an ancillary procedure known as a block graft or sinus augmentation are needed to provide enough bone for successful implant placement. There is new information about intravenous and oral bisphosphonates (taken for certain forms of breast cancer and osteoporosis, respectively) which may put patients at a higher risk of developing a delayed healing syndrome called osteonecrosis. Implants are contraindicated for some patients who take intravenous bisphosphonates. The many millions of patients who take an oral bisphosphonate (such as Actonel, Fosamax and Boniva) may sometimes be advised to stop the administration prior to implant surgery, then resume several months later. However, current evidence suggests that this protocol may not be necessary. As of January 2008, an oral

bisphosphonate study reported in the February 2008 Journal of Oral and Maxillofacial Surgery, reviewing 115 cases that included 468 implants, concluded "There is no evidence of bisphosphonate-associated osteonecrosis of the jaw in any of the patients evaluated in the clinic and those contacted by phone or e-mail reported no symptoms."[38] The American Dental Association had addressed bisphosphonates in an article entitled "Bisphosphonate medications and your oral health,"[39] In an Overview, the ADA stated "The risk of developing BON [bisphosphonate-associated osteonecrosis of the jaw] in patients on oral bisphosphonate therapy appears to be very low...". The ADA Council on Scientific Affairs also employed a panel of experts who issued recommendations [for clinicians] for treatment of patients on oral bisphosphonates, published in June 2006. The overview may be read online at but it has now been superseded by a huge studyencompassing over 700,000 casesentitled "Bisphosphonate Use and the Risk of Adverse Jaw Outcomes." Like the 2008 JOMS study, the ADA study exonerates oral bisphosphonates as a contraindication to dental implants.[40] Bruxism (tooth clenching or grinding) is another consideration which may reduce the prognosis for treatment. The forces generated during bruxism are particularly detrimental to implants while bone is healing; micromovements in the implant positioning are associated with increased rates of implant failure. Bruxism continues to pose a threat to implants throughout the life of the recipient.[41] Natural teeth contain a periodontal ligament allowing each tooth to move and absorb shock in response to vertical and horizontal forces. Once replaced by dental implants, this ligament is lost and teeth are immovably anchored directly into the jaw bone. This problem can be minimized by wearing a custom made mouthguard (such an NTI appliance) at night. Postoperatively, after implants have been placed, there are physical contraindications that prompt rapid action by the implantology team. Excessive or severe pain lasting more than three days is a warning sign, as is excessive bleeding. Constant numbness of the gingiva (gum), lip and chinusually noticed after surgical anesthesia wears offis another warning sign. In the latter case, which may be accompanied by severe constant pain, the standard of care calls for diagnosis to determine if the surgical procedure insulted the IAN. A 3D cone beam X-ray provides the necessary data, but even before this step a prudent implantologist may back out or completely remove an implant in an effort to restore nerve function because delay is usually ineffective. Depending upon the evidence visible with a 3D X-ray, patients may be referred to a specialist in nerve repair. In all cases, speed in diagnosis and treatment are necessary.

[edit] Market
In the United States and the United Kingdom, there is no exclusive specialty in 'implantology'. Any practitioner who carries out implant treatment, whether in the surgical insertion or the final provision of the prosthesis, must be adequately trained. Legal training requirements differ between countries.

In 2008, in the UK the General Dental Council (GDC) laid down strict training requirements[42] for dentists involved in dental implantology. Any dentist in the UK who wishes to train in the field of dental implantology must take part in an extended learning program which covers a detailed theory syllabus, as approved by the GDC,[43] in addition to formal supervised surgical training and mentoring. Dentists must not take part in implant dentistry in the UK until they have been approved by the training provider as having passed a formal competency assessment. Failure to comply with the GDC regulations may result in a dentist being removed from the Dental Register and hence losing the right to practice dentistry in the UK.[44] The fast growing demand for prosthetic solutions based upon dental implants caused the birth of literally hundreds of different brands available on the market, about 150 in the UK[45] and even more than 300 in Italy[46], but only a very few of these have enough documentation and clinical practice for being wordly recognized.[46]. According to a study published in the Clinical Implant Dentistry and Related Research, only three brands of implants were tested by at least two independent (not sponsored) clinical researches[47], which should push the patients to ask for more informations before accepting any treatment, and to demand for a real implant passport.[46]

[edit] See also References

1. ^ Anh, M-R; An K-A, Choi J-H, Sohn D-S (2004). "Immediate loading with mini dental implants in the fully edentulous mandible". Implant Dent 13 (4): 367372. PMID 15591999. 2. ^ Four Linkow textbooks online. 3. ^ Annali di Stomatologia - Su alcuni casi particolarmente interessanti di impianto endosseo con vite autofilettante - Vol XV - Aprile 1966 4. ^ US patent 3579831, Stevens, Irving J.; Alexander, Jerry, "Bone Implant", issued 1971-05-25 5. ^ Quirynen M, Van Assche N, Botticelli D, Berglundh T (2007). "How does the timing of implant placement to extraction affect outcome?". The International Journal of Oral & Maxillofacial Implants 22 Suppl: 20323. PMID 18437797. 6. ^ Crespi R, Cappar P, Gherlone E, Romanos GE (2008). "Immediate versus delayed loading of dental implants placed in fresh extraction sockets in the maxillary esthetic zone: a clinical comparative study". The International Journal of Oral & Maxillofacial Implants 23 (4): 753 8. PMID 18807574. 7. ^ Gahlert M, Rhling S, Wieland M, Sprecher CM, Kniha H, Milz S (November 2009). "Osseointegration of zirconia and titanium dental implants: a histological and histomorphometrical study in the maxilla of pigs". Clinical Oral Implants Research 20 (11): 124753. doi:10.1111/j.1600-0501.2009.01734.x. PMID 19531104. 8. ^ Depprich R, Zipprich H, Ommerborn M, et al. (2008). "Osseointegration of zirconia implants: an SEM observation of the bone-implant interface". Head & Face Medicine 4: 25. doi:10.1186/1746-160X-4-25. PMC 2583968. PMID 18990214. 9. ^ Andreiotelli M, Kohal RJ (June 2009). "Fracture strength of zirconia implants after artificial aging". Clinical Implant Dentistry and Related Research 11 (2): 15866. doi:10.1111/j.17088208.2008.00105.x. PMID 18657150. 10. ^ Arturo N. Natali (ed.) (2003). "Dental Biomechanics". Taylor & Francis, London / New York, 273 pp., ISBN 9-780-415-30666-9, pp. 69-87. 11. ^ Osseointegration, Zard et al. Quintessence 2009.[verification needed]

Mini dental implants (MDIs) are small diameter dental implants. Dental implants may be split into two separate categories based on the diameter of the device. Small diameter dental implants, most often referred to as Mini Implants, are those with a diameter less than three millimeters (3mm.) Likewise, standard or conventional implants are those implants larger than 3mm in diameter, but most commonly 4- 5mm. As a rule of thumb, Mini Dental Implants are at least half the price of conventional implants and sometimes a quarter of the price of conventional implants.[1][2] Mini dental implants, or MDI's, are sometimes referred to as SDI's (small diameter implants), as well as NDI's (narrow body implants). Although mini dental implant is actually a trade name for the most widely used small diameter implant, the 3M ESPE MDI Mini Dental Implant, the dental industry has adopted the term to describe this class of implants. Some small diameter implants are used as anchors in orthodontic cases and are called TADs, or temporary attachment devices. One example of a TAD is the Unitek Temporary Anchorage Device System. These differ from the more common mini dental implants in that they are removed after they are no longer needed and orthodontic treatment is completed. Mini Dental Implants are constructed of various titanium alloys. The same applies to traditional implants.

Mini Dental Implant by 3M ESPE


1 Design 2 Uses 3 Procedure 4 See also 5 References

[edit] Design

Currently, mini dental implants have a diameter of 1.8mm to 2.9mm and are offered in various lengths. It is important to note that the pull out strength of an implant has been shown to be based on its length rather than its diameter.[3] Multiple tip, thread, body and head designs are available across the category as well. Most tip designs are sharp or slightly blunted to provide self tapping ability of the implant through the medullary bone. Some blunted designs taut a compression of the bone as an advantage. Thread designs vary from thin to thick and thread spacing is also variable. The design variations allow for use of the implants in the different densities of bone (D1-very dense, D2, and D3-soft) found throughout the mouth. The body connects the tip with the prosthetic head and can be a parallel sided cylinder or a progressively tapered cone. The aforementioned design elements contribute to enhancing initial stability. The choice depends again on the bone density encountered in the desired implant location. For one piece dental implants such the minis, the concept of initial (mechanical) stability is paramount for success. This is based on mechanical retention of the implant in the bone (See the osseointegration page), as well as the strength of the implant. There can be statistically significant differences in the strength of the implant. According to Binon, adequate mechanical characteristics are needed for an implant to resist functional occlusal loads.[4] The prosthetic head allows the dental prosthesis to connect to the implant and anchor it to the bone. It also connects to the implant driver during placement. Square, rectangular, or o-ball heads are common and connect easily to a simple set of corresponding drivers. Fixed crowns or bridges can be cemented directly to the square or cubic head of the mini. Subsequently, a sphere was milled into the square portion of the head allowing for a more elegant restorative solution. This o-ball design became a popular solution to secure loose dentures. Other standard prosthetic options for removable and fixed solutions do exist and custom options are available from various dental labs.

[edit] Uses
Mini dental implants are extremely valuable for endentulous patients that have loose lower dentures and want an easy solution to secure them in place.[5] Most denture patients have highly resorbed jawbones (Mandible and/or maxillary bones) and bone augmentation, aka bone graft, is required for a standard dental implant solution. Moreover, health status of many senior citizens contraindicates invasive dental treatment, such as a conventional implant. In contrast to conventional implants, a survey of 200 clinicians indicated that a flap procedure was mostly (80% of the time) unnecessary for placing MDI's.[6] Healing time is decreased, as the ability to avoid flap surgery aids in healing (the periosteum is left undisturbed)[7][8] and immediate satisfaction achieved with this minimally invasive approach. The shorter treatment time translates to lower costs as well; an important factor because implants are not typically covered by dental insurance programs. Although not as widely utilized, many MDIs are FDA approved to be used for fixed crown and bridge installations as well.[9][10] Proper case selection is critical but the available literature has demonstrated success that rivals standard implants. This means if you are missing a tooth or multiple teeth, a mini implant may be placed and a crown fabricated to cement on to the head of the implant.

Another important indication for Mini Dental Implants is the transitional stabilization indication. In this instance, Mini Dental Implants are used to give temporary support to the denture while the conventional implants and bone graft are healing.[9]

[edit] Procedure
Mini dental implants are placed in a flapless and minimally invasive procedure under local anesthetic[11][12]. This is in sharp contrast to conventional implants, which are often placed in a procedure requiring a flap, bone graft, and/or significant healing time[13]. In the United States, using mini dental implants to secure a lower full denture is a generally accepted indication. A number of mini dental implants are placed in the mandible and these implants will be used to secure the denture (as opposed to adhesive materials or other methods of stabalizing the denture). For most types of mini dental implants, a small hole will need to be drilled before inserting the implant.

Pilot hole being drilled for Mini Dental Implants

Four Mini Dental Implants in mandible

[edit] See also

WHAT IS A DENTAL IMPLANT? An endosteal (within) bone alloplastic biologically compatible material surgically inserted into the edentulous bony ridge, which serves as a foundation for prosthodontic restoration. History of endosseous dental implants dates back to the Egyptians. In 1913 Greenfield patented a two-stage system similar to the ones in use today. The "father of modern implantology", Formiggini in 1947 developed the helical wire spiral a precursor to our modern day dental implant systems. Endosseous implants may be single stage - one piece from bone through oral mucosa - such as the crystal sapphire implant, or two-

stage - bony implant separate from the transmucosal portion. Numerous designs and materials exist for the two-stage variety. The most commonly used biomaterials for endosseous dental implants are commercially pure (CP) titanium and titaniumaluminum-vanadium (Ti-6Al-4V) alloy. Ti-6Al-4V types are stronger and used with smaller diameter implants. Titanium is lightweight, biocompatible, corrosion resistant, strong and low-priced. High corrosion resistance is attributed to an inert oxide layer that provides the basis of biocompatibility with the surrounding tissues. Common fixture types include HA (hydroxyapatite) coated, Ti surface-modified, tap or self-tapping, and screw or press fit. Brnemark in the late 1980s defined the term "osseointegration" as a direct structural and functional connection between ordered, living bone and the surface of a load-carrying implant. A soft-tissue relationship similar to the natural dentition exists (sulcular epithelium). Hemi-desmosome like structures connect the epithelium to the titanium surface, however there is no connective tissue insertion, nor intervening Sharpeys fiber attachment, only circumferential and perpendicular connective tissue. At the bone-implant interface osteoblasts are in close proximity to the interface, separated from the implant by a thin amorphous proteoglycan layer. Osseointegration is highly predictable. At the bone-implant interface, a mineral-ion interaction occurs, as evidenced by the continued growth of the oxide layer (2000 at 6 years). Bone deposition and remodeling occurs in response to stress and stimulation as the implant is loaded. Components and terminology of dental implants are ever-changing as newer systems are being developed. (Basic "parts" are presented in Fig 2.2.) Modern dental implants are small - usually 3.75mm or larger in diameter for a standard abutment, up to 6.0mm for a wide body or wide platform. Implant lengths typically range from about 7 to 18 mm. The surface and design of implants should be evaluated for each anatomical location, along with size, length, and diameter. Most endosseous dental implants favor a two-stage approach, with the bony implant separate from the transmucosal portion. For FPDs it is

advised to use screw-retained restorations with at least two fixtures when restoring posterior spaces not bound by natural teeth. In an attempt to "standardize" implant systems, the United States Navy uses the "external hex" system. Favorable long-term research literature exists, and this system is relatively easy to maintain. A wide variety of implant designs exist, discussion of which is beyond the scope of this handout, however the US Navy has focused on the Nobel Biocare and 3i systems. A newer design of abutment is the two-piece abutment post, which is designed to resemble a crown preparation. Claims of simplicity of treatment with cement-retained crown to the abutment, and for use when limited posterior access with screwdriver presents. Another product is a single stage implant which uses a specific microtopographic acid-etched surface fixture design, advocates loading after 2 months, and claims 98% success after 3 years is the "Osseotite" system by 3i. Long-term research shows that osseointegration of dental implants is highly predictable. Most implants have over a 10-year, 80-95% survival rate, and have become a definitive treatment option for restoring edentulous areas, but do not eliminate the underlying prosthetic challenges. ADVANTAGES no preparation of tooth/adjacent teeth length of treatment time bone stabilization & maintenance risk of fixture failure retrievability length of treatment time improvement of function need for multiple surgeries DISADVANTAGES

psychological improvement challenging esthetics


"Diagnosis begins with a complete patient evaluation"

Guidelines for "decision-making" process: treat the "entire" patient & restore form, function & esthetics:

Treatment planning phase o problem list & patient desires o initial evaluation chief complaint medical/dental history review intra/extraoral exam evaluation of existing prosthesis diagnostic impressions/articulated casts radiographs (panoramic and periapical, CT scan or tomography as indicated) photographs o treatment options/informed consent o explanation of long-term commitment o restorative - surgical joint consult o two-stage surgery (using clear acrylic surgical stent is mandatory!)

stage I : implant fixture placement w/ cover screw (left

submerged); healing phase 3 month minimum (mandible) usually 6 months for posterior regions; 6 month minimum (maxilla) usually 6-9 months for all regions stage II : uncovering and placement of transmucosal healing abutment; healing phase 4-6 weeks for soft tissue healing
o o o

restorative phase maintenance and regular recall fee & payment policy

goal to restore form, function & esthetics

Problem list & treatment considerations

teeth number & existing condition including:

prognosis of remaining teeth size, shape & diameter of existing dentition tooth & root angulations & proximity mesiodistal width of edentulous space **Need: minimum of 6-7mm between teeth to facilitate implant placement (based on 3mm fixture) > 1.5mm between implant and natural teeth 7mm from center of implant to center of implant for edentulous area **If more than 10mm mesiodistal space then single tooth implant not recommended (multiple abutments should be splinted)

periodontium -

bone support quality & quantity (Lekholm & Zarb classification)

quality: best is thick compact cortical bone w/ core of dense

trabecular cancellous bone best region is mandibular symphysis; poorest in posterior regions

quantity: required for implant placement:

6mm buccal-lingual width w/ sufficient tissue volume 8mm interradicular bone width

10mm alveolar bone above inferior alveolar (IAN) canal or below maxillary sinus **If inadequate bone support, may need ridge or site augmentation: ramus or chin graft (autograft) DFDBA (allograft) Bio-Oss(xenograft) **implants should be placed at a minimum of 2mm from the inferior alveolar (IAN) canal or below the maxillary sinus bone quantity bone quality crown/root ratio mobility furcations probing depths mucogingival problems sufficient tissue volume is necessary to recreate the gingival papilla; some attached gingiva is necessary to maintain the periimplant sulcus *bone resorption in the 1st year post-extraction will result in loss of 1.5mm since crest of bone is optimal 2-3 mm below the level of the CEJ --implant should be placed 2-3mm apical to free gingival margin (or CEJ) of adjacent tooth for necessary width to restore the biologic width and create the peri-implant sulcus

* soft tissue heights of < 2mm or > 4mm may present a challenge! oral hygiene important pre and post-implant placement! systemic manifestations ie. diabetics are predisposed to delayed healing destructive habits smoking is contraindicated to placement of implant as delayed or inadequate tissue healing and osseointegration is noted

radiographic analysis -

periapical pathology radiopaque/radiolucent regions adequate vertical bone height in edentulous area 10mm alveolar bone above inferior alveolar canal or below the maxillary sinus adequate space above IAN or below maxillary sinus **implants should be placed at a minimum of 2mm from the inferior alveolar canal or below the maxillary sinus adequate interradicular area - 8mm interradicular bone width bone quality & quantity (as previously discussed) radiographs - panoramic and periapical - (CT scan or tomography as indicated) panorex and periapical radiographs will help to determine amount of "space" available and amount of bone available

Use of computed tomography (CT) scan gives a more accurate & reliable assessment of bone (quality, quantity and width) of alveolar crest, including location of anatomic structures *radiographic stent - use of an acrylic stent (which can double as the surgical stent) with lead beads or ball-bearings (5mm) placed in proposed fixture locations allows more accurate radiographic interpretation distortion (common to all radiographs) Panorex ~ 25% vertical; horizontal varies with head position (1.20 1.25x) CT ~ 1:1; 1-2mm vertical error; *most accurate (1.0 1.1x) Lateral Ceph ~ 8% Periapical ~ 2.5 - 5%

surgical analysis

*surgical guide stent - is one of the most critical factors for obtaining an ideal surgical & esthetic result used during installation of implant fixture as guide for optimal B/L and M/D position; use of a buccal channel drill guide allows improved access and visibility

implant length/diameter determined by quantity of bone apical to extraction site use longest implant that can be used safely; diameter dictated by corresponding root anatomy at crest of bone

treatment options immediate implant placed at time of tooth extraction - delayed immediate - (8-10 week delay from extraction) - delayed - (9-10 months or longer) **some feel that immediate is best, as bone does not resorb following extraction, others feel delayed placement allows bone fill for stabilization (proper surgical technique during implant placement is critical to success ) * surgical handling of the tissues with minimal heat generation is paramount - (< 47 Celsius for one minute or less) provides the most predictable healing response

esthetic analysis

smile line - high in maxilla; low in mandbile lip shape full Vs. thin existing ridge defect if visible w/ high smile line will need augmentation implant emergence profile (360 ) restored implant should appear to "grow or emerge from the gingiva and provides a restoration with a very natural and desirable appearance ** avoid "tomato on a stick" crowns or periodontal problems may develop

occlusal analysis

improvement of function and/or esthetics (?) parafunctional habits can be destructive; need to determine reason for tooth loss - if lost to occlusal trauma/parafunction, less success predicted for implants diagnostic casts mounted to determine opposing occlusion (watch for supererupted opposing teeth) watch occlusal plane ridge width - 6mm buccal-lingual width w/ sufficient tissue volume existing vertical space between arches need absolutely 14-15mm for complete denture; variable w/ partially edentulous depending on type implant

maxillo-mandibular relations jaw classifications Class II may have greatest benefit; Class III requires surgical intervention

advs/disadvs of proposed treatment are as individual as the case being treatment planned! Consider: cost, patient desires, clinician abilities, etc. referrals/specialty consults: can prognosis be improved with (?) -

orthodontics periodontal therapy endodontic therapy

pre-prosthetic surgery extractions, ridge contouring or removal of exostosis, osteotomy, orvbone or soft tissue augmentation

appointment sequencing - length of treatment time and need for multiple surgeries

treatment alternatives fixed partial dentures; removable partial dentures; resin-bonded fixed partial dentures; orthodontics, or do nothing! (no treatment and leave patient as is!)

INDICATIONS CONTRAINDICATIONS good general health unrealistic patient expectations free of disease alcohol/drug dependence adequate bone quality & volume parafunctional habits appropriate occlusion & jaw relations psychological factors inability to wear conventional prosthesis anatomical factors unfavorable number/location of abutment inadequate ridge/interarch dimensions single tooth loss immunosuppression RELATIVE CONTRAINDICATIONS (need surgical intervention) Inadequate bone at implant site or excessive bony concavities (chin or ramus graft to correct) Inadequate vertical space (sinus lift or inferior alveolar nerve (IAN) transposition)


Primary goal is to protect and maintain "tissue integration"; good oral hygiene is a key element!

Criteria for success (most important is good diagnosis!)

no peri-implantitis (sulcular plaque accumulation w/ associated loss of "pseudo-epith" attachment) no peri-implant radiographic radiolucency marginal bone loss of 1.0-1.5mm first year after placement; then < 0.1mm bone loss per year tissue integration: bone/soft tissue ("osseointegration") absence of mobility stable clinical attachment level absence of bleeding upon probing/excessive probing depths absence of discomfort success rate varies with bone quality, loading dynamics, etc. ** anticipated success rates of +97% in anterior mandible and 90% in maxilla success decreases in posterior quadrants due to poorer bone quality (10 yrs) ** best bone: good cortical with some cancellous for vascular supply

Maintenance and Recall

Four elements

home-care regimen

periodic recall reinforcing regimen strict adherence to recall schedule and

verification of function, comfort, and esthetics

lifetime maintenance commitment

Frequency of recall
Immediate post-delivery; 24 hours; one week; two weeks (re-torque if needed); 6 months; then

bi-annual or annual evaluation

Clinical Parameters of Evaluation


oral hygiene (including plaque index)

plaque is primary etiologic factor in tissue destruction (peri-implant and natural tooth) review of oral hygiene instruction is important at each recall session monitor oral hygiene through plaque indices same hygiene requirements as for natural teeth use neutral sodium fluorides only as acidified fluoride gels can etch and damage the titanium implant surface

implant stability (evaluate mobility)

mobility - may be the key indicator of fixture health minimal mobility is associated with osseointegrated fixtures: 17-57 um buccal; 17-66 um lingual

** there is no significant difference in osseointegrated fixture mobility relative to fixture length (Sekine etal) implants may sustain extensive bone loss without increasing mobility if a critical amount of bone remains (amount not clearly defined)


a failing implant fixture may be masked if it is connected to the same prosthesis (eg. FPD), and therefore it is important to remove the FPD to evaluate all fixtures recommendation for annual removal and evaluation for all multipleunit prosthesis early failure detection will minimize fibrous tissue zone development size and may allow for successful placement of a wider diameter fixture

peri-implant tissue health

visual inspection should include evaluation for signs of pathoses including: alterations in color, contour, and consistency of soft tissues alveolar mucosa may surround implant and may appear more erythematous (redder) than the surrounding gingiva any soft tissue movement of peri-implant tissue upon tension to bordering areas should be considered detrimental since it may adversely affect the soft-tissue-implant attactment ; a soft-tissue autograft should be perfomed to correct this problem ** perimucosal keratinized tissue is best

crevicular probing depths

** the most accurate means of detecting peri-implant destruction

use plastic probes to avoid damaging the titanium implant surface probing measurements closely approximate the actual bone levels

avoid probing during the first 3 months after abutment connection to avoid damaging the weak epithelial attachment probing may be difficult if the fixture threads are supra-osseous due to marginal bone loss -- the probe can get directed into the upper thread surface by the connective tissue that has formed around these threads


controversy exists as to the significance of bleeding on probing (BOP)at the peri-implant interface Lekholm study found sulci with no histologic signs of inflammation which bled clinically; howeverlater studies (same author) have shown a positive correlation between BOP and inflammation BOP may precede clinical signs of inflammation ** BOP and radiographic changes are the most valid indicators of peri-implant breakdown recommendation for continued use of peri-implant sulcus probing to monitor implant success

radiographic assessment (serial)

** one of the most valuable measures of implant success radiographs are of value when: * cannot probe area due to constricted implant or connective tissue impingement * to assess future mobility without FPD removal * to accurately determine amount of bone loss in absence of increased crevicular depth radiographs are important when used to compare bony changes with stable landmarks ** use implant threads (one-half thread = 0.3mm)

can compare horizontal and vertical implant dimensions between serial radiographs

periapical radiographs = 2.5 5% image magnification Vs. direct clinical measurements

** bone level determination should be based only upon standardized periapical radiographs
threads of implant must appear sharp and well-delineated on X-ray to be accurate X-ray beam: direct 9 from a line perpendicular to the long axis of the implant Film placement: keep parallel and close to the implant KVp: recommended not < 60 (best is 65-70) Exposure time: determined upon ability to visualize internal mechanical structure of fixture Long-cone paralleling technique recommended with paralleling film holder Use of intra-oral landmarks and film holder to standardize horizontal angulation quality in film development is paramount!! recommended post-op radiographic intervals: *not between fixture placement to abutment connection as healing tissue may respond unfavorably to radiation exposure *one week after abutment insertion *immediately following fixed prosthesis insertion, then 6 months later *annually for the first 3 years, then every 2 years (varies)

** expect 1.0mm marginal bone loss during the first year postinsertion, then 0.1mm per year anticipated thereafter rapid bone loss may be seen if: fractured fixture is present initial osseous trauma at time of insertion fixture over-tightening occlusal trauma poor adaptation of the prosthesis to the abutment "normal" physiologic response (?) plaque-associated infection (peri-implantitis)

Remember.. endosseous implants may lose extensive amounts of bone support without showing any rather obvious radiographic changes or increase in mobility detectable in periodontally involved teeth!!!

proper torque on screw joints

loosened screws are the most common problem and can result in localized inflammation, loose restorations, and discomfort if re-torquing a loose abutment be careful not to strip or "roundoff" the hex excessive force can fracture the screw or implant, or create increased stresses in the bone (use the proper tool ie. screwdriver for the job!)

occlusion (implant- protected)

"implant protected occlusion" light centric only; no contact in lateral excursions

excessive force concentrations can result in extensive bone loss and implant fracture major cause: poor abutment prosthesis adaptation other factors: poor force distribution and improperly planned occlusal schemes BEST: anterior guidance (however group function or balanced occlusion can also work) goal: is to prevent lateral forces on posterior implants concentrated in cervical area ideal is "light centric" occlusion only no contact in lateral excursions; no contact in MI, but with hard clench teeth will hold shim stock (.0001 ) ** a relationship exists parafunctional activity and increased marginal bone loss thus the proper occlusal scheme when planning and restoring abutments is of utmost importance!

Hygiene Aids

Implant maintenance should include a thorough review of oral hygiene instruction, and scaling of the implant abutment surfaces: plastic scalers ONLY!! - should be used for abutment scaling to prevent easy abrasion of the

titanium metal fixtures, and should be only used in ONE direction starting at the gingiva (best are from 3i) plastic periodontal probes should also be used ultrasonic scalers NO!! use of theTitan-S or like ultrasonic scaling devices are not recommended unless used with special nonmetal tips prophy jets - are to be used with caution * Any surface damage of the implant will facilitate increased plaque and calculus retention, and may hinder tissue attachment, thus recommendation is for use of fine pumice or fine prophy paste with blue rubber tipped prophy cups. Use of Super floss or Post-care (nylon fibers) thread is recommended for interproximal use between abutments and under extensions. end-tufted or small intedental brushes (Proxibrushes) - also recommended for cleaning buccal and lingual abutment surfaces all metal surfaces must be nylon coatedelectric toothbrushes use at discretion of dentist, however they may be useful for patients with limited manual dexterity chlorhexidine may be use during the peri-surgical period, or as needed for episodes of acute soft tissue inflammation; caution patients about "staining" possibilities fluoride rinses or gels recommended use of neutral sodium fluoride to avoid damage to titanium

fixtures that may occur with acidulated types (can etch and damage the titanium implant surface) - Probster et al study ** unless cemented, the prosthesis should be removed, evaluated, and reinserted every 1-2 years

Problems soft tissue reactions

most common due to loose screws - however poor oral hygiene can lead to "peri-implantitis and may result in progressive bone loss with lack of attached periabutment soft tissue leading to failed or failing implants treatment: remove the offending screw, tighten abutment and reinsert prosthesis reinforce oral hygiene may require soft-tissue autograft or replacement of a failed implant

fractured or loosened screws

should be the 1st suspicion when patient complaint of "loose" implant or discomfort ** important to use the correct screwdriver for screw head without excess force or can "round off" or strip hex if retrieving ("teasing out") fractured screw - be cautious not to damage hex

failing or failed implant (important to decide which!)

or is it "implantitis" Vs periodontal disease (?) failing implant clinical signs may include: progressive crestal bone loss, soft tissue

pocketing, BOP with possible purulence, and tenderness to percussion or torque causes may include: surgical compromise (bone overheating, lack of initial stability), nonpassive superstructure, too rapid initial loading, functional overload, inadequate screw joint closure, or infection treatment: remove and replace with larger diameter fixture, or treat infection and reevaluate; interim: remove prosthesis and abutments and irrigate with CHX, disinfect components and reinsert failed implant (most noted at Stage II) clinical signs may include: mobility, "dull" percussion sound, periimplant radiolucency, and a connective tissue implant encapsulation which may not be visible on the radiograph causes may include: surgical compromise (bone overheating, lack of initial stability), nonpassive superstructure, too rapid initial loading, functional overload, inadequate screw joint closure, or infection treatment: removal of implant "implantitis" Vs. periodontitis clinical signs are similar to each other in presentation with same pathogenic microorganisms causes may include: poor oral hygiene, bacteria, or may be unknown (?)

treatment: consults to provider and consider remaking restoration or guided tissue regeneration, etc.; interim: remove prosthesis and abutments and irrigate with CHX, disinfect components and reinsert

broken attachment or components

remove offending attachment (if possible) and replace or provisionalize * care not to damage external hex or scratch titanium fixture or abutment

CASE SELECTION 1. Case #1 46-y/o male presented with failing NSRCT #27 and severe localized periodontitis. The tooth was deemed hopeless and extracted. 4.0 x 18mm Nobelpharma fixture placed, and Cera-One abutment restored with cemented (Ketac Cem) PFM crown. (Implant recommended) 2. Case #2 31-y/o female presented with missing #19 & 30, retained #17 and #32, and mesial angulated #18 & 31. Inadequate mesial-distal and interarch distance and buccal-lingual ridge width for restoration with implants. Treatment included: Bilateral ramus grafts, extraction of #17 & 32, and molar uprighting #18 & 31. 5.0 x 11.5mm 3i fixtures placed; restored with screw retained non-segmented UCLA abutments w/PFM crowns; super-erupted #3 & 14 restored with PFM crowns. (Implant recommended) 3. Case #3 34 y/o male with past history of supernumerary #28 and dilacerated root on #28 to mesial, without adequate bone facially or room between adjacent tooth apices. After two years of orthodontic therapy #28 failed to move to facilitate implant

placement, and edentulous space was restored with a resinbonded fixed partial denture (RBFPD) #27-28. (Implant NOT recommended)

REFERENCES 1. Albrektsson T, Zarb GA, The Branemark Osseointegrated Implant; Chapter 8 by Langer B and Becker W; Quintessence Books 1989, 127-138. 2. Bauman GR, Mills M, Rapley JW, Hallmon WH, Clinical Parameters of Evaluation During Implant maintenance; Int J Oral Maxillofac Implants, 1992 (7), 220-227. 3. Becker W, Becker BE, Keys for Successful Implant Esthetics; Contemp Esth and Rest Pract, Nov/Dec 1998, Vol. 2 (6), 14-24. 4. Beumer J III, Lewis SG, The Branemark Implant System Clinical and Laboratory Procedures; Ishiyaku Euroamerica, Inc. 1989, 1519. 5. Block MS, Kent JN, Guerra LR, Implants in Dentistry; WB Saunders Company 1997, 13-86. 6. Engleman MJ, Clinical Decision Making and Treatment Planning in Osseointegration; Quintessence Books 1996, 1-113. 7. Garber D, The Esthetic Dental Implant: Letting Restoration be the Guide; JADA, Vol. 126, March 1995, 319-325. 8. Hobo S, Ichnida E, Garcia LT, Osseointegration and Occlusal Rehabilitation; Quintessence Books 1991, 55-85 9. McKinney RV Jr., Endosteal Dental Implants; Mosby 1991, 293314, 352, 421-388. 10. Misch CE, Contemporary Implant Dentistry; Mosby 1993, 3-193, 705-760. 11. Niimi A, Ueda M, Keller EE, Worthington P, Experience with Osseointegrated Implants Placed in Irradiated Tissues in Japan and the United States; Int J Oral Maxillofac Implants 1998; 13:407-411. 12. Nilson H, Lind HT, Magnusson S, Restorative Dentists ManualBranemark System,

PRI 27895.12; A2-A7, Appendix on patient selection, Nobelpharm 1992. 13. Orton GS, Steele DL, Wolinsky LE, The Dental Professionals Role in Monitoring and Maintenance of Tissue-Integrated Prosthesis; Int J Oral Maxillofac Implants, 1989 (4), 305-310. 14. Parel SM, Sullivan DY, Esthetics and Osseointegration; Taylor Publishing Company 1989, 19-34. 15. Peterson LJ, Ellis E, Hupp JR, Tucker MR, Contemporary Oral and Maxillofacial Surgery; 3rd edition, Mosby 1998, 355-390. 16. Probster L, Lin W, Huttemann H, Effect of Fluoride Prophylactic Agents on Titanium Surfaces; Int J Oral Maxillofac Implants, Vol 7 (3), 1992, 390-394. 17. Saadoun AP, LeGall MG, Periodontal Implications in Implant Treatment planning for Aesthetic Results, Prac Periodont Aesthet Dent 1998, 10(5): 655-664. 18. Salama H, Salama MA, Garber D, Adar P, The Interproximal Height of Bone: A Guidepost to Predictable Aesthetic Strategies and Soft Tissue Contours in Anterior Tooth Replacement; Pract Periodont Aesthet Dent 1998; 10(9): 1131-1141 19. Shepherd NJ, A General Dentists Guide to Proper Dental Implant Placement from an oral Surgeons Perspective, Compendium, Vol. 17 (2), Feb 1996, 118-130. 20.Taft, RM, Dental Implantology; Naval Dental School Course 223, Oct-Dec 1997. 21. Worthington P, Lang BR, LaVelle WE, Osseointegration in Dentistry: An introduction; Quintessence Books 1994, 69-83. Note: Nobelpharma has changed its name to Nobel Biocare

Implant Size Selection

The appropriate implant length and width depends upon the available bone and the expected occlusal loads. In general, choose the widest but not necessarily the longest implant possible. Panoramic and periapical radiographs as well as diagnostic models and a clinical examination are used to determine if enough mesio-distal space and vertical bone height exist to place a Bicon implant safely and appropriately in a proposed site. A transparent ruler or an implant radiograph overlay, which depict implant outlines of actual size and 125% of actual size, is helpful in selecting an appropriately sized implant. Since radiographs are not necessarily precise representations, knowledge of their magnification must be considered while using them to determine an appropriately sized implant.

Implant Size Recommendations: The following chart contains recommendations only. Actual clinical conditions and the clinicians assessment of the patient should be the main criteria for choosing the

size of an implant for a particular area.

* Recommended for two stage surgical procedure.

Keys to Success

The 3.5mm diameter implants are generally for mandibular anterior teeth. If practical, their use should be avoided for maxillary anterior and all posterior teeth. The 5.0 x 6.0mm implant is capable of supporting any tooth in the dental arch. From the canine posteriorly, if practical, place one implant per tooth being replaced.

Consider using Integra-CP implants in poor quality or grafted bone. It is advisable to have at least 1.0mm of bone around the implant. Therefore, an advisable bone width is 5.5mm to comfortably accommodate a 3.5mm implant, unless ridge splitting or grafting techniques are employed to widen the site. In the anterior maxilla, it is advisable to place MAX 2.5 Implants. The width of the alveolar bone may be assessed with a periodontal probe or caliper. It is advisable to have 1.0mm of bone around an implant for a longterm favorable prognosis. For maxillary anterior implants, always anticipate the potential need for ridge splitting or bone grafting techniques.

Pre-Surgical: Measurement of Bone

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Care must be taken to avoid the inferior alveolar nerve and the mental foramina in the premolar region, since the mandibular nerve is often inclined coronally in this area.

Care must be taken to avoid the penetration of the submandibular fossa which is located below the mylohyoid line, and particularly the sublingual space in the anterior mandible where the sublingual artery is located. Inadvertent penetration of these lingual plates may be avoided by appropriately directing the pilot bur and reamer burs toward the buccal and monitoring the area with digital contact while drilling.

The location of the maxillary sinus and nasal floor must be positively identified to avoid their inadvertent penetration with a reamer or an implant.

In general, 2.0mm of bone should separate the apex of the implant osteotomy and the mandibular canal.

Keys to Success

Examine patient with mouth closed to ascertain if there is enough interocclusal space for the intended prosthesis. A frenectomy may be advisable, to improve the soft tissue environment around the intended prosthesis. Computer Aided Tomography (CAT scan), although usually not necessary, can be of value in determining the best implant placement sites where there is minimal bone or concern as to the exact location of anatomical structures.

Instrumentation: Tray Contents

Comprehensive Surgical Kit (click numbers for more information)

1. Shoulder Depth Gauge

Designed to facilitate the proper abutment height when using the Brevis or Stealth Shouldered Abutments. It may be attached to the handle depicted in #3. [Back to Top]

2. Removal Wrench

The removal wrench is designed to loosen hand reamers, osteotomes, chisels and bone expanders from a threaded straight handle or a threaded knob. [Back to Top]

3. Double Ended Osteotomy Depth Gauge

The double ended osteotomy depth gauge is designed to facilitate the measuring of the osteotomys depth. [Back to Top]

4. Threaded Straight Handle

The straight handle is designed to be used with all threaded instrumentation: hand reamers, sulcus reamers, inserters/retrievers, tissue punches, osteotomes, chisels, bone expanders, seating tips and impression reamers. [Back to Top]

5. Implant Inserters/Retrievers

The inserters/retrievers are designed for use with either a threaded knob or a threaded

straight handle to assist in the placement and retrieval of certain implants depending upon the clinical situation. It is essential for a clinician to understand how an implant is disengaged from the inserter/retriever instrument prior to using it intra-orally. [Back to Top]

6. Threaded Offset Handle

The offset handle is designed for use with implant and abutment seating tips when direct access is not possible. [Back to Top]

7. Latch Reamers

The latch reamers are designed to prepare an osteotomy and to harvest autogenous graft material without irrigation at a maximum speed of 50RPM. Two lengths are available to accommodate a variety of clinical situations. Markings are placed at 6.0, 8.0, 11.0, and 14.0mm. [Back to Top]

8. Latch Reamer Extension

The latch reamer extension is designed to lengthen a latch reamer to facilitate access when adjacent teeth interfere with the handpiece head. If the latch reamer is not fully engaged in the latch extension prior to being used, the latch reamer may become stuck or permanently damaged in the latch reamer extension. [Back to Top]

9. Pilot Drills

The pilot drill is available in two different lengths depending upon the access to the osteotomy. They are designed to prepare the initial pilot osteotomy at 1000RPM and to establish the osteotomys trajectory. Markings are placed at 6.0, 8.0, 11.0, and 14.0mm. They may be used for 15-20 surgeries. [Back to Top]

10. Healing Plug Removal Instruments

The removal instruments are designed to facilitate the removal of the healing plug from the implants well during the second stage surgical procedure. [Back to Top]

11. Paralleling Pins

The paralleling pins are designed as an aid to properly align pilot osteotomies and subsequently the implants. The Comprehensive and Advanced Surgical Kits contain (2) 0 pins, and (1 each) 15 and 25 pins. The Introductory Surgical Kit contains one of each paralleling pin. [Back to Top]

12. Osteotomes

The Bicon Osteotomes are available in 5 diameters corresponding to Bicon implant diameters. They may be placed on either a threaded straight handle or an offset handle and are used for internal sinus lifting procedures. [Back to Top]

13. Implant/Abutment Seating Tips

The seating tips are designed for use with a threaded straight or offset handle to facilitate the proper seating of an implant or an abutment. When using the implant seating tips, it is imperative that the seating tips be fully seated into the well of the implant. [Back to Top]

14. Hand Reamer Extension

The hand reamer extension allows hand reamers to be used with a contra-angle handpiece. [Back to Top]

15. Hand Reamers

The hand reamers are designed to be used with a threaded straight handle to manually prepare an osteotomy. [Back to Top]

16. Guide Pins

The standard guide pins are designed to be used as a guide for the sulcus reamers. They are available in three sizes corresponding to the diameters of the internal connection of Bicon's implants. They may also be used to assess the trajectory of an implant as well as to check for how well an implant has osseointegrated. [Back to Top]

17. Sulcus Reamers

The sulcus reamers are designed to remove any soft tissue or bone above the implant that could prevent the locking taper engagement of an abutment into the well of the implant. They are used in conjunction with the guide pins in #16 above. [Back to Top]

18. Threaded Knob

The threaded knob is designed to be used with threaded instrumentation: sulcus reamers, inserters/retrievers, tissue punches, and hand reamers

Two Stage Surgical Technique: Implant Placement

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Two Stage Surgery Implant Insertion Technique

Extraction site, Envelope, Scalloped

Drill 2.0mm pilot hole with external irrigation to a depth 2.0mm3.0mm deeper than chosen implant

when practical.

Use paralleling pins to facilitate alignment when placing multiple implants.

Place an abutment with a 2.0mm post into pilot hole and confirm appropriateness with a vacupress template.

Widen socket with sequentially larger reamers Place harvested autogenous bone, intermittently without irrigation at a maximum of 50 RPM. In removed from the flutes of the reamer burs, into this case, a 5.0 x 6.0mm implant has been chosen a silicone dappen dish for later use. so the final bur used also has a diameter of 5.0mm.

Harvest bone debris from reamer flutes and socket.

The implants sterile blister pack is dropped onto a sterile tray prior to removing its Tyvek backing before the implants inner packaging is cut with a pair of scissors.

Remove implant from poly bag.

Seat implant by tapping gently on healing plug or directly into the implant well with an appropriate seating tip.

Cut healing plug. Ensure that no Place harvested bone graft over Close and wait a minimum of ten sharp edges remain that could shoulder of implant. See Step #6 to twelve weeks for irritate soft tissue. above. osseointegration.