Dental Implants

Dental Implants

1. Dental Implants Dr. Hadi munib Oral and Maxillofacial surgery resident

2. Outline Introduction Implant Components Pre-Implant biologic and Functional concepts Pre-Operative Assessment Surgical Techniques Complications References

3. Introduction Successful implant treatment is dependent on a coordinated approach combining careful treatment planning, meticulous surgical technique, and precise prosthetic restoration. The typical implant team is composed of a trained surgeon, a trained prosthetic or restorative dentist, and an experienced dental technician.

4. Implant Components Implant Fixture; Root Form

5. Implant Components Healing Abutment

6. Implant Components Cover or Healing Screw Two-stage surgical approach, prior to suturing, the implant fixture is sealed at its platform with a low profile, intra-implant cover screw.

7. Abutment

8. Crown/ Prosthesis

9. Pre-Implant Biological and Functional Concepts Hard Tissue Interface Osseointegration; The direct structural and functional connection between organized, living bone and the surface of a load-bearing implant without intervening soft tissue between the implant and bone. Clinically, asymptomatic rigid fixation of an alloplastic material (the implant) in bone with the ability to withstand occlusal forces For predictable osseointegration ,; A biocompatible material (the implant) Atraumatic surgery (Bone Temp. <47 C) Implant placement in intimate contact with bone Immobility of the implant

10. The orientation of the connective tissue fibers adjacent to an implant differ from a natural tooth. This zone of connective tissue has been measured to be 1 to 2 mm in height. Clinically, Probing depths in a healthy implant would be approximately 1 to 2 mm less than the total measured dimension from the crest of the sulcus to the alveolar bone crest. Teeth have a periodontal ligament with connective tissue fibers. Most connective tissue fibers run in a direction more or less parallel to the implant surface. Pre-Implant Biological and Functional Concepts

11. PREOPERATIVE ASSESSMENT AND TREATMENT PLANNING Initial Observations and Patient Introduction; Patient’s observation Chief Complaint; Goals, Expectations, functional or aesthetic Medical History and Medical Risk Assessment; Only a few absolute medical contraindications to implant therapy. Relative contraindications; Diabetes Osteoporosis Immune compromise (HIV infection, AIDS) Medications (e.g., bisphosphonates—oral and intravenous) Medical treatments such as chemotherapy and irradiation (e.g., of the head and neck)

12. Intraoral Examination; implant-focused The restorative integrity of existing teeth, existing prosthetics Vestibular depths Palatal depths, edentulous ridge topography Periodontal status Oral lesions, infections, occlusion, jaw relationships, inter-arch space, maximum opening, parafunctional habits, and oral hygiene. Soft Tissue; Keratinized PREOPERATIVE ASSESSMENT AND TREATMENT PLANNING

13. Radiographic Examination Periapical Occlusal Panoramic Cephalometric CT and CBCT. Cost, availability, radiation exposure, and the type of case. PREOPERATIVE ASSESSMENT AND TREATMENT PLANNING

14. Areas of study radiographically include the following: Location of vital structures: • Mandibular canal • Anterior loop of the mandibular canal • Anterior extension of the mandibular canal • Mental foramen • Maxillary sinus (floor, septations , and anterior wall) • Nasal cavity • Incisive foramen PREOPERATIVE ASSESSMENT AND TREATMENT PLANNING

15. 2. Bone height 3. Root proximity and angulation of existing teeth 4. Evaluation of cortical bone 5. Bone density and trabeculation 6. Pathology (e.g., abscess, cyst, tumor) 7. Existence of anatomic variants (e.g., incomplete healing of extraction site) 8. Cross-sectional topography and angulation (best determined by using CT and CBCT) 9. Sinus health (best evaluated by using CT and CBCT) 10. Skeletal classification (best evaluated with the use of lateral cephalometric images) PREOPERATIVE ASSESSMENT AND TREATMENT PLANNING

16. Critical measurements specific to implant placement include the following: At least 1 mm inferior to the floor of the maxillary and nasal sinuses Incisive canal (maxillary midline implant placement) to be avoided 5 mm anterior to the mental foramen 2 mm superior to the mandibular canal 3 mm from adjacent implants 1.5 mm from roots of adjacent teeth PREOPERATIVE ASSESSMENT AND TREATMENT PLANNING

17. Maxilla vs. Mandible The posterior maxilla poses two specific concerns related to implant placement: The quality of bone in this area; less implant stability at the time of placement. The proximity of the maxillary sinus to the edentulous ridge; pneumatization of the sinus, If there is inadequate bone height, “sinus bump” or “sinus lift” procedure would be necessary

18. Surgical Instruments

19. Pre-Operative Medications An oral dose of 2 g penicillin V 1 hour preoperatively or an intravenous dose of one million units penicillin G immediately preoperatively are effective. Alternative medications include 600 mg clindamycin orally or intravenously. No postoperative antibiotic administration is necessary

20. Implant Site Exposure Flapless surgery Tissue elevation; sulcular , mid-crestal, and vertical-releasing incisions. Flapless surgery may be indicated when there is adequate keratinized tissue over an ideal ridge form. Mid-crestal incision: Through the keratinized tissue, being sure to get the blade up against the mesial–distal surfaces of the teeth adjacent to the edentulous space. Vertical-releasing incision: Using a sharp #15 blade, a curvilinear, beveled (approximately 45 degrees), papilla sparring incision should be made to reduce or eliminate incision scarring.

21. Surgical Technique The speed should be set at 1000 to 1500 revolutions per minute (rpm) for the precision and pilot drills. All drills should be copiously irrigated Drilling is done with the precision drill at full speed to a depth of 1 to 2 mm short of the depth of the intended implant (e.g., 8 mm deep for a 10-mm implant). The area is irrigated and the 2-mm pilot drill positioned in the exact same location after verifying the correct angulation. Once position and angulation are confirmed, the 2-mm pilot drill is run at full speed to the intended depth of the implant (e.g., 10 mm deep for a 10-mm implant). The osteotomy is then inspected with a thin instrument for possible bone perforation (e.g., sinus communication or buccal wall perforation). Immediately after completing the osteotomy, the speed of the motor is changed to 30 newton centimeters ( Ncm ) for the insertion of the implant.

22. Complications Pain, bleeding, swelling, or infection. A positioning error resulting in implants placed at a compromised angulation or position Surgical technique complications such as a tear of the soft tissue flap, poor closure of the incision, or excessive soft tissue trauma may result in tissue dehiscence, infection, and eventual loss of the implant. Invasion of critical anatomic structures can create more serious complications. Invasion of the canal of the inferior alveolar nerve may result in paresthesia (non-painful) or dysesthesia. If the implant invades the maxillary sinus or the nasal cavity, this may result in an infection. Incision line opening can occur from inadequate suturing or not having tension-free closure. Esthetic complications can occur from poor implant positioning or angulation, making proper prosthetic restoration unrealistic. Mechanical complications can present as an implant platform fracture because of excessive insertion torque.

23. References Chapter 14: Implant Treatment: Basic Concepts and Techniques

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