IMPLANTOLOGI Compressed Compressed (1) - Min
IMPLANTOLOGI Compressed Compressed (1) - Min
IMPLANTOLOGI Compressed Compressed (1) - Min
Oral Implantology
India’s Most Extensive Single Day Implant Course
Diameter
o Varies between 2.5mm to 5.5mm
Zirconium
Pure(CP) titanium
lightweight
biocompatible
Removable implant :-
o Rod itself is not removable, but the tooth that screws into the
rod is.
o This form of prosthesis includes an artificial white tooth with a
plastic pink gum to appear realistic.
o Tooth snaps into the metal rod, and is typically removed at
night.
Advantages
• Easy to remove for repairs
• Can cover a wider area for
multiple missing teeth for a lower
cost
Fixed implant prosthesis
o Stays in place all the time,
o Either due to permanently being screwed into the
metal rod or because the implant has been
cemented in place
Advantages
o More secure than removable implants
o Can be cleaned and treated like normal teeth.
Procedure
o Surgical procedure (for 3-9 months)
o First surgery:- insert titanium post in the bone or gum
of mouth
o Patient sedated gum is cut holes are drilled
o titanium cylinder placed cylinder covered
by stitched(self dissolving) metal cylinder
osseointegrate with bone(2-6 month)
o swelling, bruising, pain, and minor bleeding around the
gum area is expected
o Pain reliever and antibiotics given for
pain and further infection
During the procedure
After the bone gets merged with metal ,second surgery
is done
gum is reopened expose previously implanted
metal rod abutment attached
who would rather not have two surgeries, the
abutment placed within the gum during the
first.(bone is still healing teeth is not placed yet)
Imaging is done before and after dental
implants placement to assess bone characterstics
at the site of insertion
High resolution CT imaging (0.625 mm slices)
Assessment of analytical damage
DATA MEASURED
o Bone type
o Bone thickness
o Density
surrounding the tip and parrallel section of
microimplant
Advantages
o Feels and chews like real teeth
o Doesn’t alter neighbouring teeth
o Completely secure after healing
o Better for long-term oral health
o Looks identical to real teeth
o Can be used for one tooth or several
o Easy to care
o High success rate of around 95%
o bone stabilization & maintenance
Disadvantages
o Expensive
challenging esthetics
What is involved with getting a dental implant?
Only patients who need a replacement tooth will be
benefited
to correct cosmetic problems, such as having
discoloured or missing teeth.
those who have lost teeth due to gingivitis eligible for
dental implants.
patients should be of adult age( as children and
teenagers still have their jaw bones growing)
Classification of the topography of the IAN. (A = the nerve has a course near the
apices of the teeth, B = the main trunk is low down in the body, C = the main trunk
is low down in the body of the mandible with several smaller trunks to the molar
teeth.
Neuro-Vascular Considerations
Below the lateral pterygoid muscle it is accompanied by the inferior alveolar artery, a
branch of maxillary artery. The artery also enters the canal. In the canal the IAN lies
downward and forward, usualy below the tip of the teeth until below the first and
second premolars, at this point it divides into incicive and mental branches as the
terminal branches. It continues forward in the canal or in a plexiform distrubition and
giving off branches to the first premolar, canine and incisor teeth, and associated labial
gingiva. Just before entering the mandibular canal the IAN gives off mylohyoid branch
which pierces the sphenomandibular ligament and occurs a shallow groove on the
medial surface of the mandible. It passes below the origin of mylohyoid muscle to lie on
the surface of the muscle (Standring et al., 2005;Snell, 2011).
The mandibular foramen placed on midway between the ventral and dorsal magrin of
ascending ramus of mandible nearly 1 cm above the occlusal surface of the lower teeth.
The small triangular lingula guards the anterior border of the mandibular foramen and
provides attachments for he sphenomandibular ligament from which the mandible
swings.
In many cases there is a single nerve which runs a few
millimeters below the roots of teeth, nearly equal number of the
nerve lies much lower in the mandible to continue near the
lower border of the bone, or sometimes it is plexiform. The nerve
can lie on the lingual or buccal side of the mandible (Standring
et al., 2005; Snell, 2011). The MN, a branch of the IAN, when
emerges through the mental foramen and then divides into three
branches that supply the skin of the chin and mucous membrane
of the lower lip and gum. Two of them pass upward and forward
nearby the mucosal surface of the lower lip. The third one passes
through the intermingled fibers of platysma and depressor
anguli oris muscles to harvest the skin of the lower lip and chin.
As the MN is one of the two terminal branches of the IAN, it is
understandable why one’s chin and lover lip on the affected side
lose sensation, as well.(Standring et al., 2005; Snell, 2011)
The MN is significant during surgical procedures of, the chin
area such as genioplasty and mandibular anterior segmented
osteotomy (Westermark et al.,1998; Seo et al., 2005; Gilbert &
Dickerson 1981), and it can also be damaged during dental
procedures such as dental implant surgery, orthodontic
treatment, and endodontic treatment. Mental neuropathy also
may be caused by systemic diseases and tumors (Bodner et al.,
1989; Klokkevold et al., 1989; Chand et al., 1997).
A relatively common problem is the use of an inappropriate
attachment depth or path during the insertion of dental implant
fixtures, which may injure the IAN and MN. The incidence of
permanent sensory disturbance to the lower lip after dental
implant insertion in the mental foramen region is reportedly 7%
to 10%. (Wismeijer et al., 1997; Mardinger et al., 2000).
Complications such as loss of lip and chin sensation may result
in lip biting, impaired speech, and diminished salivary retention,
deficits that have a significant impact on a cases’ activities of
daily living (Deeb et al., 2000; Smiler, 1993) .
Nerve Morphology
The nerve trunk is surrounded of four connective tissue sheaths. These are the
mesoneurium, epineurium, perineurium, and endoneurium from the outside inward
(Polland et al., 2001).
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One stage “non-submerged” implant placement
Flap designs, incisions and elevation
Implant site preparation
Flap closure and suturing
Postoperative care
Conclusion
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General principles of implant
surgery
Patient preparation
Implant site
preparation
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Patient preparation
1. Explanation of risks and benefits to the patient.
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Basic principles of implant therapy
1. Implants must be sterile and made of a biocompatible material (e.g., titanium).
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Surgical site preparation
1. Patient drape
2. Rinsing or swabbing the mouth with chlorhexidine gluconate
for 1 to 2 minutes immediately before the procedure.
3. Atraumatic implant site preparation.
4. Avoid damage to bone or vital structures
5. Copious irrigation to avoid heating and debris removal.
6. The implant must be placed in healthy bone.
7. The surgical site should be kept aseptic.
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Operative requirements
1. Good operating light
4. A surgical drilling unit which can deliver relatively high speeds (up to 3000 rpm) and low drilling
speeds (down to about 10 rpm) with good control of torque
5. An irrigation system for keeping bone cool during the drilling process
6. The appropriate surgical instrumentation for the implant system being used and the surgical
procedure
8. The appropriate number and design of implants planned plus an adequate stock to meet
unexpected eventualities during surgery
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Operative requirements
9. The surgical stent
12. A third person to act as a get things in between to and from the
sterile and non-sterile environment.
13. Light handles should be autoclaved or covered with sterile aluminum
foil.
14. The instrument tray and any other surfaces which are to be used are
covered in sterile drapes.
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One stage VS two stage technique
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One stage technique
In the one-stage approach, the
implant or the abutment
emerges through the
mucoperiosteum/gingival
tissue at the time of implant
placement.
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Advantages of one stage
Easier Mucogingival management around the implant.
Patient management is simplified because a second
stage exposure surgery is not necessary.
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Two stage technique
In the two-stage approach, the top of the implant
and cover screw are completely covered with the
flap closure.
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In areas with dense cortical bone and good initial implant support, the
implants are left to heal undisturbed for a period of 2 to 4 months,
whereas in areas of loose trabecular bone, grafted sites, and sites with
lesser implant stability, implants may be allowed to heal for periods of 4
to 6 months or more.
Longer healing periods are indicated for implants placed in less dense
bone or when there is less initial implant stability (i.e., slight looseness
caused by limited bone-to-implant contact), regardless of jaw or specific
anatomic location.
In the second-stage (exposure) surgery, the implant is uncovered and a
healing abutment is connected to allow emergence of the
implant/abutment through the soft tissues, thus facilitating access to the
implant from the oral cavity.
The restorative dentist then proceeds with the prosthodontic aspects of
the implant therapy (impressions and fabrication of prosthesis) after soft
tissue healing.
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Advantages of 2nd stage surgery
Situations that require simultaneous bone augmentation procedures at
the time of implant placement because membranes can be covered by
primary flap closure, which will minimize postoperative exposure.
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Two stage “submerged” implant
placement
The first stage ends by
Suturing
So the implant remains submerged and isolated from the oral
cavity.
Mandible implants – 2 to 4 months
Maxillary implants – 4 to 6 months
Longer periods –
less dense bone
Less initial implant stability
Shorter periods –
More dense bone
Altered surface microtopography
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In second stage
The implant is uncovered and a healing abutment is
connected to allow emergence of the implant through
the soft tissue, thus facilitating access to the implant
from the oral cavity.
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Two stage “submerged” implant
placement
Flap design, incisions, and elevation
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Incisions
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Implant site preparation
A mucoperiosteal (full-thickness) flap is reflected
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Tissue management f or a two-stage implant
placement.
A, Crestal incision made along the crest of the
ridge,
bisecting the existing zone of keratinized mucosa.
D, Tissue approximation to
achieve primary flap closure
without tension
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Implant site preparation
Sequence of drills used
for standard-diameter (4.0-
mm) implant site osteotomy
preparation:
round,
2-mm twist,
pilot,
3-mm twist, and
countersink.
Bone tap (not shown here)
is an optional drill that is
sometimes used in dense
bone
before implant placement.
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A series of drills are used to prepare the osteotomy site
precisely and incrementally for an implant. A surgical
guide or stent is inserted, checked for proper
positioning, and used throughout the procedure to
direct the proper implant placement.
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Round bur
A small round bur (or spiral drill) is used to mark the
implant site(s). The surgical guide is removed, and the
initial marks are checked for their appropriate buccal-
lingual and mesial-distal location, as well as the positions
relative to each other and adjacent teeth.
Slight modifications may be necessary to adjust spatial
relationships and to avoid minor ridge defects. Any changes
should be compared to the prosthetically-driven surgical
guide positions.
Each marked site is then prepared to a depth of 1 to 2 mm
with a round drill, breaking through the cortical bone and
creating a starting point for the 2-mm twist drill.
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Round bur/ spiral drill
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2MM twist drill
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Twist drills (To Enlarge the
Osteotomy Site to required
diameter)
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Pilot drill
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Guide pins
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Depth gauge
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Counter sink drill
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Bone tap
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As the final step in preparing the osteotomy site in dense
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It is better to allow the threaded implant to “cut”
its own path into the osteotomy site.
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In partially edentulous cases, limited jaw opening or proximity to
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When wide-diameter drills are used for implant site
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Implant site preparation (osteotomy ) for a 4.0-mm diameter, 10 mm length
screw-type, threaded (external hex) implant in a subcrestal position.
A, Initial marking or preparation of the implant site with a round bur. B, Use of
a 2-mm twist drill to establish depth and align the implant. C, Guide pin is
placed in the osteotomy site to confirm position and angulation.
D, Pilot drill is used to increase the diameter of the coronal aspect of the
osteotomy site.
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E, Final drill used is the 3- mm twist drill to finish preparation of the osteotomy site.
F, Countersink drill is used to widen the entrance of the recipient site and allow for
the subcrestal placement of the implant collar and cover screw.
G, Implant is inserted into the prepared osteotomy site with a handpiece or
handheld driver.
note: In systems that use an implant mount, it would be removed prior to
placement of the cover screw.
H, Cover screw is placed and soft tissues are closed and sutured
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Wrench / Ratchet: Fits on top of fixture mount & used
to tighten fixture after placement.
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Implant fixtures
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Cover screw
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Flap closure and suturing
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Once the implants are inserted and the cover screws secured, the surgical sites should be
thoroughly irrigated with sterile saline to remove debris and clean the wound.
One of the most important aspects of flap management is achieving good approximation
and primary closure of the tissues in a tension free manner.
Once the periosteum is released, the flap becomes very elastic and is able to be stretched
over the implant(s) without tension.
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One suturing technique that consistently provides the desired result is
a combination of alternating horizontal mattress and interrupted
sutures.
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Post operative care
Simple implant surgery in a healthy patient usually
does not require antibiotic therapy.
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Patients should be instructed to maintain a relatively soft diet
after surgery.
Then, as soft tissue healing progresses, they can gradually return
to a normal diet.
Patients should also refrain from tobacco and alcohol use at least
1 week before and several weeks after surgery.
Provisional restorations, whether fixed or removable, should be
checked and adjusted so that impingement on the surgical area
is avoided.
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Second stage exposure surgery
For implants placed using a two-stage “submerged”
protocol, a second-stage exposure surgery is necessary
after the prescribed healing period.
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Simple circular “punch” incision
In areas with sufficient zones of keratinized tissue, the
gingiva covering the head of the implant can be exposed
with a circular or “punch” incision
Alternatively, a crestal incision through the middle of the
keratinized tissue and full-thickness flap reflection can be
used to expose implants.
This latter approach may be necessary when bone has
grown over the implant and needs to be removed.
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Clinical view of stage two, implant exposure surgery in a case with adequate
keratinized tissue.
A, Simple circular “punch” incision used to expose implant when
sufficient keratinized tissue is present around the implant(s).
B, Implant exposed.
C, Healing abutment attached.
D, Final restoration in place, achieving an esthetic result with a good
zone of keratinized tissue. 110
Clinical v iew of stage two implant exposure surgery in a case with inadequate
keratinized tissue.
A, Two endosseous implants were placed 4 months previously and are ready to be
exposed.
B, Two vertical incisions are connected by crestal incision.
C, Buccal partial thickness flap is sutured to the periosteum apical to the emerging
implants.
D, Gingival tissue coronal to the cover screws is excised using the
gingivectomy technique.
E, Cover screws are removed, and heads of the implants are cleared.
F, Abutments are placed. Visual inspection ensures intimate contact between the
abutments and the implants.
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G, Healing at 2 to 3 weeks after second-stage surgery .
H, Four months after the final restoration. Note the healthy band of
keratinized attached gingiv a around the implants.
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Post operative care
remind the patient of the need for good oral hygiene
around the implant and adjacent teeth.
rinse can be used to enhance oral hygiene for the
initial few weeks after implant exposure.
oral hygiene procedures to avoid dislodging any
repositioned or grafted soft tissues.
any direct pressure or movement directed toward the
soft tissue from a provisional prosthesis can delay
healing and should be avoided.
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Impressions for the final prosthesis fabrication can
begin about 2 to 6 weeks after implant exposure
surgery, depending on healing and maturation of soft
tissues.
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One stage “non-submerged”
implant placement
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In the one-stage implant surgical approach, a second
implant exposure surgery is not needed because the
implant is exposed (per gingival) from the time of implant
placement
In the standard (classic) implant protocol, the implants are
left unloaded and undisturbed for a period similar to that
for implants placed in the two-stage approach
(i.e., in areas with dense cortical bone and good initial
implant support, the implants are left to heal undisturbed for
a period of 2 to 4 months,
whereas in areas of loose trabecular bone, grafted sites,
and/or minimal implant support, they may be allowed to heal
for periods of 4 to 6 months or more).
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In the one-stage surgical approach, the implant or the
healing abutment protrudes about 2 to 3 mm from the
bone crest, and the flaps are adapted around the
implant/abutment.
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Flap design, incisions, and
elevation
The flap design for the one-stage surgical approach is
always a crestal incision bisecting the existing
keratinized tissue.
Facial and lingual flaps in posterior areas should be
carefully thinned before total reflection to minimize
the soft tissue thickness (if needed or desired).
The soft tissue is not thinned in anterior or other
esthetic areas of the mouth to maintain tissue height
and to minimize metallic implant components from
showing through tissue.
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Implant site preparation
The primary difference is that the coronal aspect of the
implant or the healing abutment (two-stage implant)
is placed about 2 to 3 mm above the bone crest and the
soft tissues are approximated around the
implant/implant abutment.
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Flap closure and suturing
The keratinized edges of the flap are sutured with
single interrupted sutures around the implant.
Depending on the clinician's preference, the wound
may be sutured with resorbable or nonresorbable
sutures.
When keratinized tissue is abundant, scalloping
around the implant(s) provides better flap adaptation.
However, if minimal keratinized tissue exists in an
area, tissues should remain thick and soft tissue
augmentation may be indicated.
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Post operative care
The postoperative care for one-stage surgical approach
is similar to that for the two-stage surgical approach
except that the cover screw or healing abutment is
exposed to the oral cavity.
Patients are advised to avoid chewing in the area of the
implant.
Prosthetic appliances should not be used if direct
chewing forces can be transmitted to the implant,
particularly in the early healing period (first 4 to 8
weeks).
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conclusion
It is essential to understand and follow basic
guidelines to achieve osseointegration predictably.
Fundamentals must be followed for implant placement
and implant exposure surgery.
These fundamentals apply to all implant systems.
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