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BASIC PRINCIPLES
AND PRACTICE OF
ORAL IMPLANTOLOGY ANDOSSEOINTEGRATION
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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 andmarrow
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 onlyD 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 trabecularcore
3 Thin cortical plate with dense trabecular core
4 Thin cortical plate with low density trabecularcore
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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
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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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SURGICAL PROCEDURE
Smooth ridge
Use stent
Guide drill
Small twist drill
Pilot drill
Large twist drill
Depth guide
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SURGICAL PROCEDURE
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SURGICAL PROCEDURE
Countersink
Fixture insertion
Cover screw
Debridement
Closure
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POSTOPERATIVE CARE
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POSTOPERATIVE CARE
Haemostasis
Analgesia
Antibiotic regime Chlorhexidine mouthwash
Suture removal
Temporary prosthesis
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SECOND STAGE
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SECOND STAGE
Soft tissue Bone removal
Cover screw removal
Healing abutment
Replacement
Dressings
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KEY POINTS
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KEY POINTS
Implant positioning - bucco/lingual- axial
- separation
Drill speeds - 2000rpm- 20rpm
Torque
Irrigation
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MAXILLARY IMPLANTS
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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
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Countersinking
Self tapping implants
Wide implants
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COMPLICATIONS WITH
OSSEOINTEGRATED IMPLANTS
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COMPLICATIONS
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COMPLICATIONS
Preoperative
Perioperative
Postoperative
Transient
Persistent Permanent
Soft tissue
Hard tissue
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SERIOUS COMPLICATIONS
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SERIOUS COMPLICATIONS
Jaw fracture Haemorrhage
Ingestion
Inhalation
Neurological
Death
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COMPLICATIONS
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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
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O
Unsuitable morphologically Reduced bone density
Reduced bone volume
Attached tissue Nerve position
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PREVENTION OF NERVE DAMAGE
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CT Bone density measurement
Drill sleeves
Discretion is better part of valour
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COMPLICATIONS
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Peroperative
Failure to obtain anaesthesia
Haemorrhage
Stuck implant
Loose implant
Lost implant
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SURGICAL FAILURE
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Poor planning Poor surgical technique
Lack of precision
Thermal injury Faulty placement
Damage to adjacent structures
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SURGICAL
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Haemorrhage Stuck implant
Loose implant
Lost implant
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COMPLICATIONS
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Wound dehiscence
Infection
Mucosal perforation
Fistula formation
Anatomical - antral
- nasal
- neurological
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STAGE ONE SURGERY
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Failure to obtain anaesthesia Faulty placement
Anatomical
Surgical
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SURGICAL
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Stripped bone threads Exposed implant threads
Fractured drill
Sheared implant hex
Excessive countersink
Eccentric drill
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COMPLICATIONS
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Second stage
Loose implant
Excess bone coverage
Exposed threads
Coverscrew problems
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STAGE TWO SURGERY
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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
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Labial / buccal Lingual
Too close
Straight line in mandibular anteriors
Angulation
Divergence
Correct by use of a surgical template
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POSTOPERATIVE
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Fascial space infections Haematoma
Jaw fracture
Sinusitis
Wound dehiscence
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WOUND DEHISCENCE
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Poor flap design Poor surgical technique
Poor repair
Poor tissue quality
Previous surgery
Underlying medical condition
Superficial implant placement
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PERSISTENT
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Neurological damage Aesthetics
Speech
Function
Psychological
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COMPLICATIONS
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Long term
Anatomical
Neurological
Deintegration Progressive thread exposure
Gingivitis
Hyperplastic tissue Fractured Implant
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PROSTHODONTIC
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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
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Fractured fixture Fractured abutment screw
Fractured punch blade
Fractured screw driver tip
Fractured castings
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MANAGEMENT OF FAILURE
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Failing implants FAIL Removal
Abandon
Alternative site
Larger diameter
Replacement after healing
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GRAFTING TECHNIQUES
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GRAFTING
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Autogenous - Local
symphysisthird molarangletuberosity
- Distantrib
iliac cresttibiacalvarial
Allogenic - frozen- freeze dried- demineralized
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BIOMATERIALS
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- methyl methacrylate- silicone- proplast- teflon- calcium phosphates
- plaster of paris- tricalcium phosphate- hydroxyapatite- goretex
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GRAFTS
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Autogenous bone
Freeze dried bone
Synthetic biomaterials
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FREEZE DRIED BONE
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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
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Plaster of paris
Tricalcium phosphate
Hydroxyapatite
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INDICATIONS FOR GRAFTING
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Anterior maxilla
Posterior maxilla
Anterior mandible
Posterior mandible
After resection
Post traumatic
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TECHNIQUES
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Cortico-cancellous blocks
Trephined core
Sinus Lift
Vascularised bone flap
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