Basic Surgical Techniques for Endosseous Implant Placement

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Basic Surgical Techniques for Endosseous Implant
Placement
Bilozetskyi Ivan
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WHAT IS A DENTAL IMPLANT?

• Dental implant is an artificial titanium
  fixture
• which is placed surgically into the jaw bone to
• substitute for a missing tooth and its root(s).

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History of Dental Implants

• In 1952, Professor Per-Ingvar Branemark,
• a Swedish surgeon, while conducting research
• into the healing patterns of bone tissue,
  accidentally discovered that when pure titanium
  comes into direct contact with the living bone
  tissue, the two literally grow together to form a
  permanent biological adhesion. He named this
  phenomenon "osseointegration".

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First Implant Design by Branemark

• All current implant designs are modifications of
  this initial design

 
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Surgical Procedure

• STEP 1 INITIAL SURGERY
• STEP 2 OSSEOINTEGRATION PERIOD
• STEP 3 ABUTMENT CONNECTION
• STEP 4 FINAL PROSTHETIC RESTORATION

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Fibro-osseous integration
Fibroosseous integration tissue to implant
contact with dense collagenous tissue between the
implant and bone Seen in earlier implant
systems. Initially good success rates but
extremely poor long term success. Considered a
failure by todays standards
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Osseointegration

• Success Rates gt90
• Histologic definition
• direct connection between living bone and
  load-bearing endosseous implants at the light
  microscopic level.
• 4 factors that influence
• Biocompatible material
• Implant adapted to prepared site
• Atraumatic surgery
• Undisturbed healing phase

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Soft-tissue to implant interface

• Successful implants have an
• Unbroken, perimucosal seal between the soft
  tissue and the implant abutment surface.
• Connect similarly to natural teeth-some
  differences.
• Epithelium attaches to surface of titanium much
  like a natural tooth through a basal lamina and
  the formation of hemidesmosomes.

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Soft-tissue to implant interface

• Connection differs at the connective tissue
  level.
• Natural tooth Sharpies fibers extent from the
  bundle bone of the lamina dura and insert into
  the cementum of the tooth root surface
• Implant No Cementum or Fiber insertion.
• Hence the Epithelial surface attachment is
  IMPORTANT

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Subperiosteal
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Transmandibular Implant
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Blade Implant

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Endosteal Implants

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The Parts

• Implant body-fixture
• Abutment (gingival/temporary healing vs. final)
• Prosthetics

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Clinical Components

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abutment

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Team Approach

• A surgical prosthodontic consultation is done
  prior to implant placement to address
• soft-tissue management
• surgical sequence
• healing time
• need for ridge and soft-tissue augmentation

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Clinical Assessment

• Assess the CC and Expectations
• Review all restorative options
• Risks and Benefits
• Select option that meets functional and esthetic
  requirements

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Patient Evaluation

• Medical history
• vascular disease
• immunodeficiency
• diabetes mellitus
• tobacco use
• bisphosphonate use

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History of Implant Site

• Factors regarding loss of tooth being replaced
• When?
• How?
• Why?
• Factors that may affect hard and soft tissues
• Traumatic injuries
• Failed endodontic procedures
• Periodontal disease
• Clinical exam may identify ridge deficiencies

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Surgical Phase- Treatment Planning

• Evaluation of Implant Site
• Radiographic Evaluation
• Bone Height, Bone Width and Anatomic
  considerations

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Basic Principles

• Soft/ hard tissue graft bed
• Existing occlusion/ dentition
• Simultaneous vs. delayed reconstruction

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Smile Line

• One of the most influencing factors of any
  prosthodontic restoration
• If no gingival shows then the soft tissue
  quality, quantity and contours are less important
• Patient counseling on treatment expectations is
  critical

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Anatomic Considerations

• Ridge relationship
• Attached tissue
• Interarch clearance
• Inferior alveolar nerve
• Maxillary sinus
• Floor of nose

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Radiological/Imaging Studies

• Periapical radiographs
• Panoramic radiograph
• Site specific tomograms
• CAT scan (Denta-scan, cone beam CT)

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Width of Space and Diameter of Implant

• Attention must be paid to both the coronal and
  interradicular spaces

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A case against routine CT

• Expense
• Time consuming process
• Use of radiographic template/proper fit requires
  DDS present
• Contemporary panoramic units have tomographic
  capabilities
• Usually adds no additional data over standard
  database

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Image Distortion
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Anatomic Limitations
Buccal Plate 0.5mm
Lingual Plate 1.0 mm
Maxillary Sinus 1.0 mm
Nasal Cavity 1.0mm
Incisive canal Avoid
Interimplant distance 1-1.5mm
Inferior alveolar canal 2.0mm
Mental nerve 5mm from foramen
Inferior border 1 mm
Adjacent to natural tooth 0.5mm
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Dental Implant Surgery Phase I

• Aseptic technique
• Minimal heat generation
• slow sharp drills
• internal irrigation?
• external cooling

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Dental Implant Surgery Phase I

• Adequate time for integration
• Adequate recipient site
• soft tissue
• bone
• Kind Gentle technique

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Disposition
1. Chlorhexidine 2. Analgesics /- antibiotics
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Implant placement 3 months after menton bone
grafting
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Exposure of Implant during Placement
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Summers Osteotomes
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Limitations to Implant placement in the Maxilla

• Ridge width
• Ridge height
• Bone quality

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Surgical Solutions to Anatomical Limitations
Onlay Bone Graft
Sinus Lift
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Summers, RB. A New concept in Maxillary Implant
Surgery The Osteotome technique. Compendium.
15(2) 152, 154-6

• Ridge expansion technique
• 3-4 mm of crestal alveolar width required
• Sinus floor elevation technique
• 8-9 mm of alveolar bone height required in order
  to place a 13 mm implant
• (4-5 mm sinus floor elevation)

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IntroductionRidge expansion technique

• 1.6 mm pilot hole
• Summers osteotome 1-4
• sequenced tapered osteotomes.
• ridge expansion (displacement) versus bone
  removal.
• Final drill coincident with the final implant
  size (sometimes not necessary)

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IntroductionSinus floor elevation technique

• 1.6 mm pilot hole
• Summers osteotome 1-4
• Sinus floor microfractured superiorly
• Sinus floor can be elevated 4-5 mm
• May backfill with bone allograft/alloplast
• Final drill coincident with final implant size

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Surgical Technique
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A. Rake, K. Andreasen, S. Rake, J. Swift A
Retrospective Analysis of Osteointegration in the
Maxilla Utilizing an Osteotome Technique versus a
Sequential Drilling Technique, 1999 AAOMS Abstract

• 155 maxillary implants in 84 patients restored
  for at least 6 months
• 57 were placed utilizing the osteotome technique
• 98 were placed utilizing the drilling technique
• One implant failed of the 98 in the drill group
• None of the implants had failed of the 57 in the
  osteotome group

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Stage II Surgery Preoperative Considerations

• 3-6 months after stage I

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Stage II Surgery Preoperative Considerations

• Done under local anesthesia
• Pre-op medications
• Chlorhexidine rinse

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Placement of healing abutment
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conclusions

• The failing implant is very difficult to treat
• Traumatic surgical manipulation with initial
  instability of implant increases risk of failure
• Implant success is only as good as the
  prosthodontic reconstruction