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Dr.Yanal Nusair
بسم الله الرحمن الرحيم
Till this moment 16/3/09, 1:05 am,, I have no copy of the slides ,
so when u have them , go back and check if there is any extra info.
And try to match b/w wt I called "pic" in this lec & the slide that the
dr. was talking about… let's start the lec now,,, Nice one
Why do we need to talk about dental implants?? Until 10 yrs ago implants
were a luxury for most ppl. who don’t even dream of having dental
implants . Nowadays it is becoming a main stream practice. Many of the
general practitioners all over the world practice implant dentistry.
We all know that fixed prosthesis are much better in many aspects than
removable ones, bcoz they are: more stable, look more like a natural tooth,
less bulky , provide better function & esthetics.
Now without dental implants, not all pts can have fixed prosthesis, for
example, apt with free end saddle with missing posterior teeth -with no
posterior abutment - , u can't provide him with a fixed prosthesis without
dental implants .
Pts who are completely edentulous, if u don’t consider dental implants then
those pts would have the only choice of removable prosthesis.
Advantages:
1- help improve retentional stability!! of removable prosthesis in
the form of overdentures (implants & over them removeable
prosthesis)
2- With implants almost all pts can have fixed prosthesis weather
completely or partially edentulous,,, and we said (almost all) not (all)
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bcoz in some cases u don’t have enough bone to support implant or
pt general health status doesn’t permit surgical procedures,etc…
3- Implants are as close as u can get to natural teeth, u have a
fixture inside the bone (which replaces root of the tooth) & u have the
crown which (replaces the crown of natural tooth).
4- U can have separate teeth where u can insert a dental floss
between them (u can't do that if u have a bridge)u don’t have a
pontic where food can accumulate b/w it & the gingiva . so they are
similar but not the same as natural teeth .
5- More conservative ( if u want to make conventional prosthesis in
the form of bridge then u have to prepare 2 teeth , sacrifice a lot of
sound tooth structure in many cases to replace 1 missing tooth . but
with dental implants u don’t need to do that.
6- Improve esthetic, function & pt confidence (pts feel as if they
still have their natural teeth).
7- If u lose a tooth u lose the alveolus (to support teeth) or most of
it in that area. But if u insert an implant in that area, u transmit
functional stresses to the bone so u maintain it .
8- A few yrs ago they started to use dental implants to help in
anchorage in orthodontic tt. I (Dr.) don’t know what it means!!!!
Dr.: it helps u to move the correct tooth in the correct direction.
Disadvantages:
1- costly: on average u need 500 JD to get single tooth supported
by an important in Jordan ( in other countries much more
expensive)
2- Technique sensitive: u can't afford to make mistakes bcoz it will
fail and that will be very costly.
NOW…. When u drill the hole & insert the screw, wt sort of interface do
we want to achieve b/w implant surface & surrounding bone??
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Osseo-integration: we need some sort of integration b/w implant surface &
surrounding bone.
Previously they were looking for fibro-osseous-integration: where u have
the implant, the fibrous tissue resembling PDL, then bone.
Now we know that this is not valid, if an implant heals with fibro-
osseous-integration we consider it failure.
While Osseo-integration means direct connection b/w bone & implant
surface at light microscopic level .
U shouldn't see any sort of connective tissue b/w bone and implant .
At 1st few days (3-4) , neutrophils – which are acute inflammatory cells –
predominate. Then macrophages start to take over as the process
becomes more chronic.
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Then according to functional demands , there will be remodeling in the
area, for example if u place a bone graft in the area , then excess which
doesn’t support functional demands will resorb & disappear .
And this high success rates could be achieved bcoz we know the basic
necessities for Osseo-integration:
We use copious amount of saline and sharp cutting instrument " it has
been shown that heating bone up to 56°c -even if only for 1 sec- then
irreversible damage of bone takes place." "If u heat bone up to 47°c, for
more than 1 min, then irreversible bone damage will take place.
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4- Immobility of implant (u should not be able to move it more
than 100µm in any direction) during the healing phase. & this is much
more imp than precise adaptation.
We need a sort of good seal, some unbroken per mucosal seal, u want
something to seal oral fluids & saliva from the bone surrounding the
implant. For this we depend totally on epithelium, hemidesmosomes
that form b/w titanium surface & the epithelium around the implant ,
which is similar to wt u have in the junctional epithelium with a natural
tooth, but the main difference is that in natural teeth beneath junctional
epithelium we have connective tissue , but in implant u have epithelium
then bone ( no CT) , that's why soft tissue seal around an implant is
significantly less resistant to inflammation & infection compared to
natural teeth.
Biomechanical factors :
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Keep in mind that implants don’t have a PDL with proprioceptors to tell
u that u're biting too heavy , so excessive load cozes bone resorption &
if bone resorbed around an implant , it can't be compensated , so don’t
overload the implant .
Now in case of an implant, lateral forces are much more damaging , coz
implants can tolerate forces directed along their access very well , but
they can't resist lateral forces. This is why connecting implant to natural
tooth isn’t preferable ( it's not contraindicated , or wrong , but it's not
ideal ).
Suppose we have missing 6&7 , & u have 2,3,4,5 in place – sound and
good- one of the options for tt is to replace the missing 6&7 , is to place
an implant with crown in the area of 6, and another implant and crown
in the area of 7 (2 implants supporting 2 separate crowns) . however ,
the less expensive option is to place an implant in the area of 7 ,
prepare the 5 , & make a 3 unit bridge connecting the 5 to the implant
and replacing the 6 as a pontic .
This is something we don’t like , and implants don’t like , why ? bcoz if u
connect :
BUT
Implant with a natural tooth isn’t good , coz implant is very stable in
bone (doesn’t move ), while natural teeth have some degree of
movement which is less than 1mm in any direction .
Now :
* number of implants is important ,,, ideally each missing tooth should
be replaced with an implant , but this is very expensive .
If u want to use bridge , then u can use on Avg one implant for 2
crowns. So replacing 12 teeth from 6 to 6 then u need 6 implant (6-8 is
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ideal) & a lesser number of implants means overloading the implant u
have and shortening its expected life.
* angulation of implant: we are humans & our hand could move & shake
during preparing the implant site, sometimes the direction of bone
forces us to place the implant in an angle, so we don’t perforate the
buccal or lingual plates.
So ,
* if u place the implant a absolutely perpendicular to the occlusal plane →
that's the ideal .
- Cantilevers: they are not preferable. Unless u make them under very light
occlusion , just to fill the gap not to participate in function .
* pts general health status : like any surgical procedure this is something
should be taken into consideration.
* cost : full mouth rehabilitation with implant may cost 15000 JD's .
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• Plasma spray technology: where they spray droplets of molten
Ti on the surface to make it rough.
• Sand plasting .
• Acid etching.
Relative contraindications:
1- Abnormal bone metabolism: like osteoporosis, if u placed
implant, then healing time would be longer & chances of success
would be less, but still u can place implants.
2- Poor oral hygiene: if the pt can't keep his natural teeth &
change his attitude , then he would be unlikely to preserve the
implant.(coz implants are much damaging , needs highly motivated
pt)
3- Previous radiation to the implant site : this depends on dose of
radiation & duration since the last dose of radiation. Coz we worry
about osseo-radio-necrosis .
4- Unrealistic expectations: if pt expectation is unrealistic, then no
matter what u do, u won't be able to please him, he will always come
back complaining.
So tell the pt that implants are very similar to natural teeth, but they
aren’t the same .
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Phases of treatment :
Surgical phase:
The 1st thing to evaluate after pt general medical status is the implant
site.
* Any lesion in the area.
* Any remaining root.
* Any acute infection.
*Soft tissue: r they healthy? Do I have enough keratinized gingiva in the
area? Is the width & height of the ridge sufficient to support the
implant?
* Anatomic limitations:
- in mandible: how much bone do I have above the inferior alveolar
canal? if u have 5-6 mm then that is not enough to support an implant
and if u placed an implant there, u would damage the ID nerve & cause
ur pt lip numbness .
* informed consent is a must , it's not legally required yet but sooner or
later it will be . it means that the pt should know the expected results,
alternatives and possible complications (like pain, swelling ,3-4 % chance
of implant failure, etc………)
** Pic : this pt has bone resorption in this area, the width of the ridge
was insufficient, so we took some bone from the ramus, carted it to this
area, screw it → 2 months later we exposed the area, removed the
screw, place 1 implant here & 2 implants there.
This line demarcates the upper border of the ID canal , & the mental
foramen .
In order to estimate the length of ur implant , u measure the distance
from here to the crest of the ridge & keep in mind that in panorama
radiograph there is 20-30 % magnification.
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This is the area →Anesthesia → crestal incision → flap is reflected ( to
inspect the area, if there is any undercut buccally or lingually) →
prepare implant site following the instructions of the manufacturer
company. (There is a user manual which tells u the sequence of burs to
use, at wt speed, etc…………)
Usually we select the height of the implant (9mm for ex. )→ start with
initial perforator, which perforate cortical bone and then a sequence of
drills with different diameters starting with the smaller one, ending with
larger one & each time going to the full depth ( length of implant) .
Implant comes sealed & sterilized, take it out with out touching the implant
surface.→ insert it in the site u prepared → screw it slowly with special
screw driver . some implants are screwed until become flush with the crest
& others are seated sub crestally . (Depending on the system u use) .
There is an internal hex, just like a well in the implant which has a
hexagonal shape to support the abutment later on . u need to protect
the internal hex from tissue may grow there so we have something
called healing screw or cover screw to cover it→ then u suture the flap.
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Now , stage 2 surgery : after the implant has Osseo-integrated , u need
to expose it either by creating a punch in tissues on the crest of the
ridge , OR by creating a crestal incision & elevate the gingiva buccally &
lingually, OR creating apically repositioned flap.
In this stage u have to make sure that the implant has Osseo-
integrated : either:
Now I gave anesthesia →reflected a flap (u can see enough bone in all
directions , & the implant was stable)→removed cover screw with a special
screw driver→ placed wt we call healing abutment or a gingival former →
screwed it→ sutured the gingiva around it → give it 10 days – 2 weeks →
gingiva heals around it → remove the stitches .
And then the prosthetic part comes → which we will not be covering in
this case.
Complications :
in stage 1 surgery:
like any surgical procedure : pain, swelling, bleeding, etc….
now ailing or failing implant:
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Before : overheating , growth contamination , placement in an area which
doesn’t have enough bone to support it , etc….
** Key reasons for failure ( ma b3rf lesh 3adhom !!!!!)
-Off-angled positioning of more than 25° .
-Overheating during placement.
-Poor bone quality & quantity.
–Infection.
-Lack of keratinized gingiva around the implant.
Maram Bataiha
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