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ppt
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:-
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 Dental transplantation
20 Subperiosteal
Transosteal
Vitreous carbon
Blade
Osseointegrated
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RESEARCH BASE
1952-1960 Vital microscopy
1960-1968 Repair and regeneration of
bone and marrow
1965 First jaw implant
1965- 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 39 - 90
Staple 95
Vitreous carbon 50
Blade 65 - 90
Osseointegrated 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:-
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
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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 Mainly cortical plate compact bone
2 Thick compact bone with a dense
trabecular core
3 Thin cortical plate with dense trabecular
core
4 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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Smooth ridge
Use stent
Guide drill
Small twist drill
Pilot drill
Large twist drill
Depth guide
SURGICAL PROCEDURE
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Countersink
Fixture insertion
Cover screw
Debridement
Closure
SURGICAL PROCEDURE
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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 - bucco/lingual
- axial
- separation
Drill speeds - 2000rpm
- 20rpm
Torque
Irrigation
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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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Wound dehiscence
Infection
Mucosal perforation
Fistula formation
Anatomical - antral
- nasal
- neurological
COMPLICATIONS
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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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Second stage
Loose implant
Excess bone coverage
Exposed threads
Coverscrew problems
COMPLICATIONS
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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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Long term
Anatomical
Neurological
Deintegration
Progressive thread exposure
Gingivitis
Hyperplastic tissue
Fractured Implant
COMPLICATIONS
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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
Allogenic - frozen
- freeze dried
- demineralized
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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
Cortico-cancellous blocks
Trephined core
Sinus Lift
Vascularised bone flap