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7/28/2019 Os SEO Integration

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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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