9.Short and Ultra short implants auto.pptx

detailed info about short and ultra short implants and its mechanics and procedural steps

1. SHORT AND ULTRA SHORT IMPLANTS Guided by Dr. K. Prabhu MDS, Head of the Department, Department of Prosthodontics. Presented by Dr. K. SureshKumar 2nd year PG Dept of Prosthodontics Department of Prosthodontics and Crown & Bridge

2. CONTENTS INTRODUCTION DEFINITIONS RATIONALE FOR SHORT AND ULTRA SHORT IMPLANTS BIO MECHANICAL CONSIDERATIONS INDICATIONS CONTRA INDICATIONS SHORT IMPLANTS IN OVERDENTURE SHORT IMPLANTS IN POSTERIOR MAXILLA SHORT IMPLANTS IN POSTERIOR MANDIBLE SPSI IMPLANTS FACTORS RELATED TO SHORT IMPLANT FAILURE CONCLUSION

3. INTRODUCTION dental implant should always be considered as an option to replace a failing or missing tooth The replacement of lost teeth with dental implants has been in use for more than 50 years Implant placement prevents the bone loss and provides the long lasting treatment options for replacement of missing tooth

4. DEFINITIONS IMPLANT : a prosthetic device made of alloplastic material(s) implanted into the oral tissues beneath the mucosal and/or periosteal layer and on or within the bone to provide retention and support for a fixed or removable dental prosthesis (GPT10) SHORT AND ULTRA SHORT IMPLANTS : SSID (State of the Science in Implant Dentistry) S hort implant is one with a designed intra-bony length ( DIL) of 6 to 8 mm ultra-short implant has a designed intra-bony length DIL of less than 6 mm .

5. RATIONALE FOR SHORT IMPLANTS a short implant with a wider diameter provides both, improved primary stability and increased FSA.

6. BIO-MECHANICAL CONSIDERATIONS Implant diameter The wider the implant, the greater the contact area between implant surface and surrounding bone, thus improved mechanical stability and osseo -integration. Implant Shapes And Design Plateau root form Press fit sintered porous surface geometry

7. Crown Implant Ratio Increased crown/implant ratio can act as a vertical cantilever leading to further crestal bone loss and implant failure

8. TORQUE Lesser torque values ( 25Ncm) is preferable to attain axial stability Excessive force – strain related micro fractures and compression necrosis in peri implant region TAPER Resembles root Reduces bone fenestrations apically Reduces damages to adjacent teeth SPSI – 5 degree taper PRF – 3 degree taper

9. IMPLANT COLLAR DESIGN Affects the degree of crestal bone loss required to establish biological width curved machined surface-increased the length of collar available for accommodation of biologic width SURFACE FEATURES MACHINED – limited resistance to tensile forces, weak bone to implant interface CALCIUM PHOSPHATE applications - promotes rapid protein adhesion and subsequent osteo -progenitor cell attachment, proliferation, differentiation, and spreading

10. IMPLANT SPLINTING Vs. SINGLE CROWN Mandatory splinting is preferred Reduce local bone strains Redirect the stresses more axially Avoid excessive interproximal contact tightness

11. PROSTHETIC CONNECTIONS Both external and internal prosthetic abutment connections are in use most commonly morse taper arrangement is preferred. (1) they reduce micro-movements at the implant-abutment interface and loosening of retention Screws (2) they reduce stress on crestal bone, leading to less resorption (3) they can reduce the likelihood of bacterial colonies becoming established at and within the so-called microgap level of the implant

12. MODIFIED SURGICAL PROCEDURES OSTEOTOMY PROCEDURE: osteotomies that are slightly undersized in relation to implant diameter can lead to increased bone to implant contact and peri-implant bone density “Stepped osteotomy Procedure” Drilling at low speed (20 to 80 RPM) AUTOGENOUS BLOOD PREPARATIONS PRP and their inherent concentrated growth factors may enhance the speed and quality of integration.

13. SUBMERGED and NON-SUBMERGED healing protocols: Both single stage and two stage healing protocols can be employed but the submerged type reveals more success rates ADVANTAGES OF 2 STAGE SURGICAL PROTOCOL reduces the risk of early micromovements , ensuring adequate crestal bone thickness , minimizing crestal bone resorption , increasing cancellous bone-to-implant contact

14. KERATINISED GINGIVA a band of keratinized gingiva provides the peri -implant biologic seal - improve the likelihood of long-term implant success Buccal gingival biotype THICK – vertical height 2mm or greater

15. INDICATIONS Edentulous mandibular and maxillary arches. Single tooth replacement. Multiple tooth replacements to include implant supported prostheses. Inability to tolerate the material, coverage, bulk, etc. of a traditional prosthesis. The patient’s desire to not have a removable prosthesis.

16. CONTRA INDICATIONS –  Significantly medically compromised patients –  Uncontrolled diabetic patients . –  Patients who have undergone treatment with bisphosphonate-related medications –  Placement of implants in bone that has had heavy radiation exposure to both the bone and surrounding soft tissue. –  Uncontrolled immuno-suppressive disease.

17. SHORT IMPLANTS IN OVERDENTURE SUPPORT In a randomized clinical trial, Stellingsma et al compared three treatment options for rehabilitation using overdentures in patients with extremely resorbed mandibles. Treatments tested included (1) transmandibular gold alloy implants (2 ) augmentation of the mandible with interpositional grafting using autogenous iliac crest bone blocks followed by four delayed-placement standard length Implants ( 3) the placement of four short implants

18. GUIDELINES FOR USE OF SHORT IMPLANTS IN RESORBED ANTERIOR MANDIBLE submerged initial implant healing and traditional delayed loading are more appropriate An insertion torque of 45 Ncm to ensure adequate initial implant stability , and bone density in the anterior mandible The necks of the implants should be placed at the level of the lowest point of peri -implant crestal bone Ideally, the buccal bone thickness - 2 mm or more

19. CASE STUDY TREATMENT PLAN: ( 1) Four short endosseous implants to be placed in the interforaminal region of the mandible (2 ) a custom bar construction to splint the four implants together (3 ) a complete mandibular overdenture ( 4) a new conventional maxillary denture.

20. SURGICAL PROCEDURES Four 6-mm-long MRTIs (Astra Tech OsseoSpeed 4.0 S , Dentsply placed

21. PROSTHETIC PROCEDURE Preliminary alginate impression Custom tray with openings

22. Provisional healing abutments removed 20-degree Astra Tech abutments were connected Copings were connected The customized tray was assessed 1 2 3 4

23. Impression material placed around the implant copings impression material–filled Tray and exposed the copings

24. 5 year follow up

25. SHORT IMPLANTS IN POSTERIOR MAXILLA Treatment options in resorbed posterior maxilla : open lateral window sinus grafting (OSG) with delayed placement of standard-length implants Angulated zygomatic or pterygoid implants Short implant placement that does not require sinus grafting SINUS LIFTING – membrane perforation ; Presence of septa ANGULATED ZYGOMATIC PTERYGOID IMPLANTS – more skill and tedious procedure

26. GUIDELINES FOR SHORT IMPLANTS PLACEMENT IN RESORBED POSTERIOR MAXILLA Buccopalatal alveolar ridge width should be minimal thickness of 2 mm of buccal bone remains after osteotomy preparation bone density (types 2 or 3) is preferred Slightly undersized osteotomies relative to implant diameter are recommended Tapered implants - initial implant stability and reduce the risk of implant migration into the sinus Submerged initial healing is preferred Immediate loading is clearly contraindicated . Splinting of two or more implants should be planned Single crown replacement – implant placed at the site where mesial and distal teeth were present A flatter occlusal plane for the restoration may help decrease the nonaxial forces

27. CASE REPORT PRE OPERATIVE RADIOGRAPGH IMPLANT PLACED WITH COVER SCREWS 1 YEAR FOLLOW UP

28. COMPLICATIONS Maxillary posterior region – most failures – least subantral bone heights Bone density in posterior maxilla also plays a significant role in implant failures Limited visibility

29. SHORT IMPLANTS IN ATROPHIC POSTERIOR MANDIBLE Treatment options for atrophic posterior mandible (a) Distraction osteogenesis , (b) onlay grafting, (c) vGBR , and (d) inlay grafting

30. Treatment indications of different degrees of posterior vertical mandibular atrophy

31. Recommended Treatment Guidelines slightly undersized osteotomies is preferred Implant insertion with motorized handpiece and completed with manual torque wrench A minimal submerged healing interval of 4 months is suggested No removable provisional prostheses should be worn during the implant healing interval The use of at least two ultra-short MRTIs is required Screw-retained prostheses are strongly recommended The prosthesis should be designed to be as accessible as possible for oral hygiene

32. PRESS FIT - SINTERED POROUS SURFACED IMPLANTS (SPSI) a multi-layered surface of spherical metal particles created by high temperature, time-monitored , solid state diffusion surface porosity favoring vascular and bone tissue ingrowth with prosthesis fixation by 3D mechanical interlocking Endopore , Innova Life Sciences SEM view

33. do not develop high compressive stresses on the downstream side in reaction to transverse (off-axis) loads Stress concentration is uniform about the implant periphery due to effective resistance to tensile loads Sometimes it is possible to see a lamina dura –like densification of bone at the SPSI surface so they are not suitable for use in type 1 bone; sites with bone types 2 to 4 make better “ Osseoconsolidation ” – uniting and interlocking with 3d bone ingrowth (primarily frictional grip).

34. BAOSFE Technique Introduced in 1994 osteotomy development primarily using handheld end-cutting osteotome and gentle hammering with a surgical mallet an osteotome was used to up-fracture the ceiling of cortical sinus floor bone creates a tented chamber into which the implant apex could ultimately be inserted DRAWBACKS that patients may be alarmed by the idea of hammering with a mallet pathologic thickening of sinus mucosa and the presence of a blocked ostium

35. GUIDELINES FOR SUCCESSFUL SPSI Each osteotomy is initiated using a sharp pointed narrow cortical penetrating bur the tapered osteotomy-shaping burs of appropriate length and diameter are used in sequence starting with the smallest diameter to increase the osteotomy width insert a trial-fit gauge into the osteotomy to ensure that it fits precisely with no movement possible

36. The chosen implant can then be inserted the appropriately color-coded implant driver tip and surgical mallet are used to drive the implant to its full depth the sintered porous surface and the coronal machined collar segment should be buried in bone a hex-driver tip is used with firm digital force to insert the healing cap, sealing the internal prosthetic connection of the implant

37. CHALLENGES WITH SPSI High failure rates – peri implant infection Not recommended for smokers Precise osteotomy preparation is mandatory Tapered – placed with a mallet device

38. RISK FACTORS RELATED TO SHORT IMPLANT FAILURE : GENERAL FACTORS: Smoking, medical history, psychiatric considerations. LOCAL FACTORS: Poor plaque control, malocclusion, parafunctional habits OPERATOR RELATED FACTORS: Excessive trauma during surgery, implant malposition, inadequate implant numbers BIO MATERIALS RELATED FACTORS: Implant surface treatment, implant materials grade

39. CONCLUSION: the successful application of short and ultra short implants requires just as much precision and background information as any other implant-related surgical procedure shorter implants offer an approach that is minimally invasive with far less risk of complications than procedures intended to augment ridge height such as block grafting, vertical guided bone regeneration, or distraction osteogenesis .

40. REFERENCES : Short and ultra short implants by douglas deporter 2018 Quintessence Publishing Co, Inc Short implants Boyd J. Tomasetti , Rolf Ewers Springer Nature Switzerland AG 2020 Schimmel M, Srinivasan M, Herrmann FR, Müller F. Loading protocols for implant-supported overdentures in the edentulous jaw: A systematic review and meta-analysis. Int J Oral Maxillofac Implants 2014;29( suppl ): 271–286 Thoma DS, Cha JK, Jung UW. Treatment concepts for the posterior maxilla and mandible: Short implants versus long implants in augmented bone. J Periodontal Implant Sci 2017;47:2–12 Rosen PS, Summers RB, Mellado JR, et al. The bone-added osteotome sinus floor elevation technique: Multicenter retrospective report of consecutively treated patients. Int J Oral Maxillofac Implants 1999;14:853–858 Deporter DA, Pharoah M, Yeh S, Todescan R, Atenafu EG. Performance of titanium alloy sintered porous-surfaced (SPS ) implants supporting mandibular overdentures during a 20-year prospective study. Clin Oral Implants Res 2014;25:e189–e195