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Advanced

techniques in
implant
dentistry(part
Dr. Aziz Pahadwala1)

Contents

Introduction
Definition of implant related terminology
Classification
Historical background
Advanced diagnostic methods
Advanced surgical techniques.
Changing concepts in implant dentistry.
Conclusion.

Introduction
The replacement of soft tissue and hard tissue is
essential to rehabilitate and improve function and
esthetic of orofacial region. The entire scope of
replacement therapy has progressed originally
from tooth replacement to surgically oriented
implant reconstruction to the current and more
correct prosthetically driven approach.
The restorative efforts have expanded beyond the
single tooth replacement, to edentulous arch, the
partially edentulous patients, the radiated
patients and the patients with craniofacial
deformities.
Mish CE: Contemporary Implant dentistry 2nd Ed. Indiana University,
Mosby Elsevier, 2008.

On the recent times various advances have


been made to improve the implant dentistry.
Patients accept to undergo oral implant
therapy inspite of deficiency in bone.
This presentation aims at highlighting the
various advanced technique in oral
implantology such as CBCT, Zygomatic &
pterygoid implant, Ridge expansion, Ridge
splitting, onlay grafting, alveolar distraction,
sinus lift procedure and the future of above
techniques.

DEFINITION OF IMPLANT RELATED TERMINOLOGY

Osseointegration A direct structural and functional connection between ordered,


living bone and the surface of a load-carrying implant.
Endosseous dental implant
A device inserted into the jaw bone (endosseous) to support a
dental prosthesis. It is the tooth root analogue and is often
referred to as a fixture
Implant abutment The component which is attached to the dental implant to
support the prosthesis. A transmucosal abutment (TMA) is one
which passes through the mucosa overlying the implant. A
temporary or healing abutment may be used during the
healing of the peri-implant soft tissue before the definitive
abutment is chosen.
Albrektsson T, Branemark PI, Hansson HA, Lindstrom J. Osseointegration
titanium implants. Requirements for ensuring a long-lasting, direct bone
anchorage in man. Acta Orthopaedica Scand 1981; 52:155-170.

Ridge expansion Bone expansion can be defined as the manipulation of the


bone to form a receptor site for an implant without the
removal of any bone from the patient.
Sinus lift procedure Asurgical procedurewhich aims to increase the amount of
bone in theposteriormaxilla(upper jaw bone), in the area
of premolarandmolarteethby sacrificing some of the
volume of themaxillary sinus.
Ridge splitting Bone split can be defined as the manipulation of the bone
to form a receptor site for an implant without the removal
of any bone from the patient.
Babush CA, Hahn JA, Krauser JT, Rosenlicht JL. Dental implants: The art and science. 2 nd
Ed. Missouri, Saunders Elsevier, 2010.

Zygomatic implant According to Malevez et al. and Aparicio et


al. the zygomatic implants are a valid
alternative to bone grafting in patients with
advanced maxillary atrophy.
Pterygoid implant
Anendosseousimplantplacedposteriorto
themaxillaryfirstmolarupintothepteryg
oidplate.

All on four implant The All-on-4 concept using two axially implants
in the anterior region and two tilted posterior
implants has been well documented and
published by Malo P. et al.
Alveolar distraction osteogenesis Cope et al. (1999) defined distraction
osteogenesis as a process of new bone
formation between the surfaces of two
segments of a bone separate gradually for
incremental mechanics traction.

Historical background
Ancient Implants
The idea of permanently being able to replace
teeth has been a desire of civilizations since
the days of the Egyptians.
First implant- copper peg- 3000 yrs ago.
Central America- Replacing lost teeth with
animal ones.
16 th Dark stone
( Egyptian-South American)
17 th Carved ivory teeth

1809 Gold implant


e.20th Lead, iridium, tantalum,
stainless
steel, and cobalt alloy
1913 hollow basket iridium + gold
wires
(Greenfield)

1937 Adamss submergible threaded


cylindrical implant with round bottom
1938 Strocks (long term) threaded
vitallium implant
(cobalt+chrome+molybdenum)
The modern implants appear to be
variants or composites of some of the
designs of early implants

1952-Swedish surgeon, Professor


PerIngvar Branemark, coined the
term
osseointegration- pure
titanium
comes into direct
contact with the
living bone
tissue.

1965 Dr. Brnemark placed his first


titanium dental implant into a human
volunteer, a Swede named Gosta Larsson.
He received implant at the age of 34, died
at the age of 75, having used his implants
for over 40 years
1981 Nobelpharma AB founded in to focus
on dental implantology.(later to be
renamed Nobel Biocare)

1967 Linkow blade implant-in


narrow ridge
1970 Roberts and Roberts Ramus
titanium blade implant

1943 Dahl of Sweden placed with 4


projecting post
Placing implants on and around
bone rather than in it
CT-generated CAD-CAM model

1975 Small introduced transosteal


mandibular staple bone plate
Limited to mandible only

Classification
ADVANCE
D
TECHNIQ
UES
SUIRGICA
L
TECHNIQ
UES
ADVANCE
S IN
IMPLANT
S

ADVANCE
S IN
PROCEDU
RES

IMAGING

CBCT

ADVANCES IN
IMPLANTS

ADVANCES IN
PROCEDURES

ALL ON FOUR
ZYGOMATIC
IMPLANTS
PTERYGOID
IMPLANTS

GUIDED IMPLANT
SURGERY
ONLAY
AUGMENTATION
RIDGE EXPANSION
RIDGE SPLITTING
ALVEOLAR
DISTRACTION
SINUS LIFT

Classification
Advances in diagnostic imaging

Zonography
Cone beam Computed tomography(CBCT)
Microtomograph
Multi slice helical CT
Dentascan
Interactive CT

ADVANCES IN IMAGING/
DIAGNOSTIC MODALITIES
ADVANCES IN PANORAMIC IMAGING
ZONOGRAPHY
A modification of the panoramic x-ray machine
for making cross sectional images of the jaws.
The tomographic layer is approximately 5mm.
For appreciation of spatial relationship between
the critical structures and the implant site.

Zonography
Limitations:
Tomographic layers relatively thick .
Adjacent structures blurring and superimposition.
Not useful for determining the differences in
bone density or for identifying disease at implant
site.

Tomography
Tomography is the generic name
formed by the greek words
tomo(slice) and graphy(picture).
Enables visualization of a section
of patients anatomy by blurring
other regions above and below the
site of interest.
For dental implant patients, high
quality complex motion
tomography is required.

Computed tomography (CT)


Computed tomography (CT) is a digital and
mathematical imaging technique that creates
tomographic sections.
With latest CT scanners, images with sectional
thickness of 0.25 mm can be obtained .
This can be useful for determining the implant
site in terms of bone density, and location to
adjacent anatomic structures.

Recent advances in
Computed Tomography(CT)
Cone beam CT:
It uses a cone beam and reconstructs the image
in any direction using special software.
It gives all the information of a CT but, at 1/8th the
radiation dose and at a lower cost.

Software is used to display and visualize the


anatomy
in a way that is clinically
meaningful.
The manufacturers of CBCT scanners offer
software that is capable of multiplanar
reformations .

SAGGITAL CT
AXIAL CT

CROSS SECTIONAL VIEW OF MAXILLA AND MANDIBLE

Recent advances in
Computed Tomography(CT)
Microtomograph:
Modification of CT, it is specially useful in acquiring
serial sections of bone implant interface.

Multi slice helical CT:


The rapid volumetric data acquisition. The speed
was further increased by multislice CT, and offers
higher accuracy of images as compared to CT.

Dentascan

DentaScan imaging
provides
programmed
reformation,
organization and
display of the
imaging study.

The radiologist simply


indicates the curvature of the
mandibular or maxillary arch

The computer is programmed


to generate referenced cross
sectional and
tangential/panoramic images
of the alveolus along with 3-D
images of the arch.

The cross sectional and


panoramic images are spaced
1mm apart and enable
accurate preprosthetic

Limitations
1. Images may not be of true size and require
compensation for magnification.
2. Determination of bone quality requires use of
the imaging computer or workstation.
3. Hard copy dentascan images only include a
limited range of the diagnostic gray scale of the
study.
4. Tilt of the patients head during the
examination is critical

Interactive computed
tomography(ICT)
This technique enables
transfer of the imaging
study to the clinician as
a computer file.
The clinicians computer
becomes a diagnostic
radiologic workstation
with tools.

An important feature of
ICT is that the clinician
and radiologist can
perform electronic
surgery (ES)

With an appropriately
designed diagnostic
template, ES can be
performed to develop the
patients treatment plan
electronically in 3
dimensions.

ES and ICT enable the


development of 3

Transfer of the plan to the


patient at the time of
surgery can be
accomplished by
It can also be accomplished
by the production of the
computer generated, threedimensional stereotactic
surgical templates from the
digital ICT and ES data.

Limitations of ICT:
Refinement and exact orientation of the implant
positions is difficult and cumbersome.
Executing the plan may be difficult for the
surgical team.

References
1. Griffitts, TM; Collins CP, Collins PC . "Mini dental implants: An adjunct for
retention, stability, and comfort for the endentulous patient". Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 100 (5): E8184.
2. English, CE; Bohle GC . "Diagnostic,k procedural, and clinical issues with
the Sendax mini dental implants". Compendium. supplement 1 24: 123.
3. Block, MS; Delgado A, Fontenot MG . "The effect of diameter and length
of hydroxyapatite-coated dental implants on ultimate pullout force in dog
alveolar bone". Journal Oral Maxillofac Surgery 48 (2): 174178.
4. Binon, PP . "The effect of implant/abutment hexagonal misfit on screw
joint stability". Int Journal of Prosthodontics 9: 149160.
5. Shatkin, TE; Shatkin S, Oppenheimer BD, Oppenheimer AJ . "Mini dental
implants for long term fixed and removable prosthetics: A retrospective
analysis of 2514 implants placed over a five year period.". Compendium
28: 3641.

References
6. Christensen, GJ; Swift, Edward J. (2008). "Mini implants: Good or bad for
long term service?". J Esthetic Dentistry 20 (5): 343348.
7. Gibney, JW (2001). "Minimally invasive implant surgery". J Oral
Implantology 27 (2): 7376
8. Campelo, LD; Camara JR (2002). "Flapless implant surgery: A 10 year
clinical retrospective analysis". Int Journal Maxillofac Implants 17: 271276.
9. Ahn, 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): 367
372.
10. Mazor, Z; Steigmann M, Leshern R, Peleg M (2004). "Mini-implants to
reconstruct missing teeth in severe ridge deficiency and small interdental
space: A five year case series". Implant Dentistry 12: 336341.
11. Shatkin, TE; Shatkin S, Oppenheimer AJ (2007). "Mini dental implants
for long term fixed and removeable prosthetics: A retrospective analysis of
2514 implants placed over a five year period.". Compendium 28: 3641.
12. Christensen, GJ; Swift, Edward J. (2008). "Mini implants: Good or bad for
long term service?". J Esthetic Dentistry 20 (5): 343348.

End of part
1
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