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92 Cards in this Set
- Front
- Back
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Introduced Implants
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Dr. Branemark at 1983 GNYAP
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Closed Tray vs Open tray
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Open tray
- Use when implants are deeply placed or if multiple implants are angulated to one another Closed tray - Difficult access or when impression post would not be accessible to unscrew with tray in mouth |
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Sequence of Treatment
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Extract and graft
- 6wks to 9months Implant Placement - Immediate to 9 months Second Stage surgery - 2wk to 2month healing period |
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Transition from extraction to implant
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1) Removable
2) Fixed bridge 3) Nothing 4) Immediate placement and immediate load |
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Abutement Selection
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ADO
- Angle the long axis of implant makes with occlusal plane - Depth of implant below gingiva - Occluion with opposing teeth |
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Cemented
Indications, types |
- Used when angle is not favorable
- Abutment and crown are two separate pieces Types Pre-fabricated abutments: Straight or angled - Different heights, angles, and materials - Zirconia or Titanium Custom abutments: GoldAdapt or Procera |
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Procera Abutment
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- Waxup is scanned and digitalized
- Can be milled into titanium or zirconia abutments |
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Two Visit Procedure
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First visit
- Impression at Fixture Level - Record shade - Take counter impression Insertion - Contacts - Tissue: Work at proper depth 1-2mm subgingival and depends on crown - Check occlusion. Should be very light for single units - Torque abutments to 32Ncm |
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Implant Occlusion
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- No Periodontal ligament and no mobility
- Lateral forces are most detrimental to single unit implants so take them out of occlusion - Their purpose is esthetic and prevent overload or drifting of existing natural teeth |
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GoldAdapt
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Used for ALL screw retained restorations
- Can also be used for a CUSTOM Cemented Abutment - When interarch space is limited - Fixture angulation is not acceptable - Follows contours of soft tissue - Conventional restorative technique |
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Occlusal clearance for abutments
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Cemented - 4.5mm
Screwed - 3mm |
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Multiple Unit fixed restorations rules and disadvantages
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Rules
- Work no more than 3mm Subgingival - If tissue is thin, to directly to implent - If greater than 3mm use multi-unit abutment to raise platform - If implant is angled use a multi-unit angled abutment Disadvantage - Raises implant platform, so can show metal |
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Misalignments
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NP 1-7mm
RP 1-9mm WP 1-7mm - 20deg taper - Allows 40deg misalignment |
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Types of Abutments for Screw Retained multiple unit fixed bridges
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1) Non-Engaging ECLA type
2) Multi-Unit abutment 3) Angled Multi-unit abutment |
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Cement Retained Multiple fixed restorations
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- Cemented bridges must use Engaging Abutments
- So same abutments as for single unit - Impression at implant level |
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Ways to determine Passive Fit
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Frameworks must have a passive fit
- One screw test - Radiographs - One quarter turn test - Visual inspection |
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Three types of bridges
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Gold & Acrylic must be Screw retained
Porcelain and metal can be either Screw retained or Cemented |
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PFM vs Gold/Acrylic
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PFM
- More complex so increased cost - Harder to repair - Poor match to gingival tissue - However, more Durable and can Custom match to Natural teeth Gold/Acrylic - Less Durable - Good Gingival esthetics - Easier to fabricate and repair |
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Hybrids vs Overdentures
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Overdenture - Removable by patient
Hybrid - Only removed by dentist |
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Solder Index
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Must leave in after soldering for 5 minutes because solder shrinks for 5 minutes once hard
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Number of full arched implants
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Maxilla
- Minimum of 6 with 4 on each side Mandible - Minimum of 4-5 Implants between Mental Foramen |
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Types of screw retained bridges
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Cast
- Gold & Acrylic - Porcelain and Gold Scanned - Titanium & Acrylic - Porcelain and Zirconia |
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Surgical guide provides
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Acceptable Access Opening
Location of Gingival Margin Angulation of tooth Crown to tooth ratio |
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Why overdentures?
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- Missing soft tissue so poor esthetics and phonetics
- Not enough implants for fixed bridge - Inability to keep clean - Poor crown to root ratio |
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Overdenture vs Fixed bridge
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2 implants = Overdenture
6 max or 4-5 mandibular = Fixed bridge - Unless a Flange is needed |
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Degree of Implant or Tissue support
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More than 2 implants or a bar not in straight line
- Prosthesis have to be totally implant supported or it will rock |
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Types of Overdentures
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Individual implants: Easier, Lower cost, More cleansable
Splinted implants (Bar) - More implant support, requires more room |
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Bar Overdentures spacing
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- 3mm for bar
- 2mm above and below for acrylic - 2-3mm for teeth - Total of 10mm - Make implants as far apart as possible without going distally |
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Abutment Impression Coping and Analog
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Clear is heaviest
Orange Blue is lightest White is spacer |
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Distance from implant to contact point that will fill with tissue
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Implant Tooth - 5mm
Implant Pontic - 4mm Implant-Implant - 3mm |
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Space needed
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Space between implants and teeth + Width of implants + Space between implants
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Socket Classification
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Type I - Good bone and tissue
Type II - Tissue good, but bone defect. So Graft first Type III - bone and Tissue defect. Graft tissue first |
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Immediate Placement advantages
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No infection
Favorable Implant Position achievable Primary implant stability achievable Adequate soft tissue adaptation Favorable socket anatomy |
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Immediate load-temporary and Immediate function
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Immediate Load-Temporary
- Placed upon insertion of implant and is in occlusion Immediate Function refers - Temporary crown that is not for occlusion. Esthetics only and usually for single units |
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Osseointegration vs Mechanically stability
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Crosses over at 2 wks so two mark is critical
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Criteria for Immediate Temporization
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- Implant must be mechanically stable: 40ncm or greater torque
- Avoid micromovements during 1st 8wks of healing - Splint implants rigidly together - Avoid lateral forces |
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Immediate Load conclusions
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- Single units immediately loaded should never be placed in occlusion
- Multiple units should not be in a straight line for immediate load because no resistance to lateral forces |
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Noble Guide
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Treatment planning and surgical implementation system enabling transfer of extraoral planning into the mouth very accurately
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Implant materials composition
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Metals
Ceramics Polymers |
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Implant Materials biodynamics
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Biotolerant
Bioinert Bioactive All three = Biocompatible B+C = Osteoconductive |
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Reasons for failure of Biotolerant Implants
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Insufficient epithelial seal - Infection
Peri-Implant tissue proliferation - Fibrous capsule |
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Hydroxyapatite CaPO4 coatings advantages and concerns
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Advantages
- Rapid bone contact - Enhanced bone-implant contact Concerns - Microbial adhesion - Coating failure - Dissolution - Osseous breakdown |
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Ti-6AL-4V
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Fe - Corrosion Resistance
AL - Increase strength and decrease density V - Al scavenger to prevent corrosion |
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Surface modifications
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Surface roughening
- Sand blast - Dual acid etch - TiO2 Anodized oxidation surface Surface Coatings - HA - Titanium plasma spray - Flouride - Sintered titanium microspheres |
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Implant Survival vs Implant success
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Survival - Duration of implant within oral cavity
Success - Quality of the implant function and esthetics within the oral cavity |
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Peri-implant cell-tissue response
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Peri-implant epithelium
- Biological seal: Basal lamina and hemidesmosomes - Epithelial sulcus Peri-implant connective tissue - Pseudo-PD ligament - Collagen fibers parallel to surface Peri-implant bone - Rigid Support - Pseudoankylosis - Incomplete bone-implant interface |
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Peri-Implant disease
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- Collective term for inflammatory reactions in the tissues surrounding an implant
- Peri-implant Mucositis: Reversible gingivitis surrounding a functioning implant - Peri-implantitis: Periodontitis. *- BOP is very normal for implant sites |
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Implant site development objective
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Enhancing implant predictability and patient satisfaction through oral plastic surgery
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Extractions and bone levels
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Loss of teeth is accompanied by alveolar bone loss of up to 60% in first 2-3yrs after tooth loss
- Esthetic problem for fabrication of a conventional or implant supported prosthesis - Makes placement of implants difficult or impossible |
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Implant placement into exo sites
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Immediate placement
- If able to get fixation Early placement - 6-8wks after extraction for soft tissue healing Delayed placement - Bone loss severe - GBR procedure - 6mos for hard tissue healing |
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Immediate placement
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Advantages
- Combines post extraction healing period with integration phase - Bone regeneration around implant may enhance bone-to-implant contact Limitations - Difficulty with implant insertion into socket - Lack of sufficient bone for anchorage - Difficulty with achieving primary closure - Antibiotics are recommended - Greater than 93% bone fill and success rate |
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Early Implant Placement
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Advantages
- Facilitates primary closure - Allows time for infection resolution |
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Delayed implant placement
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Advantages
- Complete hard and soft tissue healing - Enhances prosthetically driven implant placement Disadvantage - Time factor |
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Posterior maxilla issues
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- Greater bone resorption in maxilla versus mandible
- Pneumatization of maxillary sinuses - Poor quality of bone associated with this region |
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Sinus Dimensions
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Mean volume - 15ml
Ostium at highest point - 30mm above floor Oval duct like shape - 6mm by 3.5mm |
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Underwood septae
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Occurence of septae - 33%
Anterior location is 77% Mean height of septae range is 7.9mm |
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Sinus infection
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Acute sinusitis or Large Cyst, refer to ENT
- Small cyst: Determine size and if elevation will block ostium |
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Pre and Post op instructions for sinus infection
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1) Mouth Rinses: Chlorhexidine rinse with 15ml BID after brushing and flossing starting a few days before surgery and 2wks after
2) Analgesics: Expect some post-op pain and discomfort. Ibuprofen 800mg one hour prior to surgery and continue to take one tablet four times a day as needed for one week 3) Decongestants: 12hr antihistamine and decongestant tablet will be prescribed to prevent congestion and nasal stiffness 4) Antibiotics: - Augmentin 875mg 1 tablet night before surgery and 1tablet BID for 7-10days. Red complex is resistant to Amox - PCN allgery: Cephalexin 500mg 1tab before surgery and 1tab TID for 3 days - PCN and Ceph allergy: Clarithromycin 500mg 1hr before and 1tab every 12hrs for 3 days. - Alternatively, Azithromycin 6 250mg tabs two on day one and one on day 2-5. If on macrolide, give 10 day statin holiday to avoid debilitating myopathy. Avoid use of clindamycin for most sinus infections. - Post op infections include Levaquin 500mg, Avelox 400mg or Metronidazol 500mg - Most infections are due to graft. - Infection for more than 10 days will require surgical intervention |
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Delayed sinus floor augmentation
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- Sinus grafting without simultaneous placement of implants
- Graft allowed to mature for 9 months prior to implant placement - Allows time for graft to reorganize and revascularize |
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Graft materials
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Autogeneous grafts - Resorption, morbidity, cost
Demineralized Freeze dried bone - Compression, resorption, poor implant survival. 85% Mineralized bone allograft - Processing issues Bovine bone mineral - Implant survival similar to that of particulate autogeneous bone grafts |
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Bovine Bone mineral and histological studies
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- Osteoconductivity
- Slow resorbability - Residual graft material does not interfere with osseointegration - 25% vital bone formation - 25% residual xenograft - 50% marrow |
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Rough vs Machined
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Rough - Clot stabilization allowing for contact osteogenesis
Machined - Clot destabilization and retraction leading to distance osteogenesis |
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Important variables
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- Particulate rather than block
- Xenografts rather than autogeneous bone or composite grafts - Rough surface rather than machined implants - membrane placement. However, no barrier for BMP because need periosteum contact for stem cells. Only use membrane for allograft or xenograft |
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Piezosurgery
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- Precision
- Selective cutting - Reduced bleeding - Minimal surgical stress - Improved healing response and safety |
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Biomimetics
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Reconstructing or mimicking natural processes or tissues with the expectation that regeneration will follow
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Tissue engineering triad
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Scaffolds - Collagen, Bone mineral, Synthetics
Cells - Mesenchymal cells, Osteoblasts, Fibroblasts Signaling molecules - Growth and differentiation factors, Morphogens, Adhesins |
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Growth and differentiation factors in clinical development
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Platelet-rich plasma
- Platelet derived growth factor - Transformine growth factor - Insulin growth factor - Not very good Platelet-derived growth factor - Insulin growth factor - Used for periodontal defects. - Not that great BMP - Recombinant or animal derived - Recombinant is very effective |
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BMP mechanism
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- Osteoinductive proteins have bone-inducing activity
- Chemotactic factor for osteoblast precursors - Inhibits formation of osteoclast like cells - Differentiation factors - Induces endochondral or intramembranous bone formation - Mesenchymal cells differentiation - Vascular invasion - Remodeling - Rapidly cleared from circulation by cell internalization and degredation - Noggin and other substances created by cells inactivates BMP activity |
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Recombinant human BMP DNA technology
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- very effective
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ACS
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Absorbable collagen sponge
- Intra-operative hemostatic agent - Bovine tendon type 1 collagen - Extensive safety record - rhBMP-2 solution applied at time of surgery |
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Implant failure
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- Clinical mobility
- Progressive bone loss despite treatment - Symptoms refractory to therapy - Adverse effects upon vital structures - Non-restorable - Implant fracture |
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Early complications/failures
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- Occurs prior to prosthetic loading
Due to inability to achieve osseointegration - Surgical trauma - Contamination of implant/surgical site - Improper preparation of the osteotomy - Lack of primary stability - Contamination of the implant surface - Infection |
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Late complications/Failures
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- Occurs after prosthetic loading
Due to inability to maintain, under functional conditions, an already achieved osseointegration - Biomechanical overload - Peri-implantitis |
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Biological Complications
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- Surgical complications
- Implant loss - Peri-implant bone loss/Mucosal inflammation - Malpositioned implants |
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Mechanical complications
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Fractured restorations
- Porcelain, long span bridges, cantilevers Overdenture complications Screw related complications - Screws loosen or fracture Abutment related complications - Loosening, incomplete seating |
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Guided Bone Regeneration
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- Reconstruction of alveolar bone defects prior to or in association with the placement of dental implants
- Objective is to recreate lost or damaged structure as close to the original form and function including esthetics |
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Overall survival rate for implants placed in sinuses augmented with lateral window
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91.8%
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Complications in Sinus Elevation
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Early Post-operative Complications
- Incision line opening - Bleeding - Barrier membrane exposure - Infraorbital nerve paresthesia Late Post-operative complications - Graft loss/failure - Implant failure - Oroantral fistula - Implant migration - Inadequate graft fill sequelae |
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Why implants Fracture
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- Compromised length and/or diameter
- Too few implants - Failure to develop site prior to placement - Non-splinted implants cross arch - Failure to treat parafunctional habits - Malocclusion - Cantilevers too long or unsupported |
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Keratinized tissue around implants
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- Lack of keratinized tissue can result in difficulty in oral hygiene and maintenance
- Increased bacterial/biofilm accumulation |
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Parasthesia
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Numb feeling
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Hypoesthesia
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Reduced feeling
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Hyperesthesia
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Increased sensitivity
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Dysthesia
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Painful sensation
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Anesthesia
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Complete loss of feeling
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Treatment for Peri-Implantitis
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- Antibiotics
- I & D - Flap and Debridement - Remove Implant |
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Implant distance
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1.3mm to buccal plate
2mm thickness on buccal and lingual 3mm inter-implant distance 4mm implant. So 8mm total needed on the alveolus |
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Roxoloid
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Strausmann
Titanium and Zirconium alloy for stronger and narrower diameter of implants - Used for thin bone or small interdental space |
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Tissue vs Bone level
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Strausmann makes tissue level
Tissue level - Have collars that come above crest of bone that help with force and reduce microgaps - Good for posteriors - Built in emergence profile - 1.25mm thread - Roughened surface - Standard with tall collar or Standard plus which is most popular and has a tapered effect Bone level - Without collars and is right at crest of bone - Collar will be part of abutment which leads to microgap - Bone control design |
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2 stage vs 1 stage
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- 1 stage reveals healing abutment
- 2 stage buries the implant under the tissue and lets it heal |
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Oxide layer interaction
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Oxide layer makes titanium act like ceramic
- Blood likes to grow on it so its like having a metal rod with ceramic coating |
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Three types of bridges
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Gold and Acrylic - Screw retained
- Not cemented because of unpredictability Porcelain and metal - Screw retained - Cemented. Still not a great choice |
