BASIC PRINCIPLES

AND PRACTICE OF
ORAL IMPLANTOLOGY AND
OSSEOINTEGRATION

AS08951.ppt
OSSEOINTEGRATION
Definition

AS08952.ppt
 OSSEOINTEGRATION

A direct structural and functional connection

between ordered living bone and the surface
of a load carrying implant

P-I Branemark

AS08953.ppt
 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 AS08954.ppt

 HISTORY

Century
17 Dental transplantation
20 Subperiosteal
Transosteal
Vitreous carbon
Blade
Osseointegrated
AS08955.ppt
 RESEARCH BASE

1952-1960 Vital microscopy

1960-1968 Repair and regeneration of

bone and marrow

1965 First jaw implant

1965- Clinical research

AS08956.ppt
 SUCCESS

 Rates
 Criteria
 Research reports

AS08957.ppt
 HARVARD SUCCESS
CRITERIA
The dental implant must provide functional
service for 5 years in 75% of cases

AS08958.ppt
 SUBJECTIVE CRITERIA

 Adequate function
 Absence of discomfort
 Improved aesthetics
 Improved emotional and psychological
wellbeing

AS08959.ppt
 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 AS089510.ppt
 SUCCESS RATES

%
Subperiosteal 39 - 90
Staple 95
Vitreous carbon 50
Blade 65 - 90
Osseointegrated 80 - 100

AS089511.ppt
 BRANEMARK SYSTEM

 Development
 Integrated Design
 Quality Control
 Precision
 Reliability

AS089512.ppt
 ALTERNATIVE
TECHNOLOGY

 IMZ
 ITI
 3M
 Corevent
 Apatite coated

AS089513.ppt
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 AS089514.ppt

INDICATIONS

 Fully edentulous

 Partially edentulous

 Single tooth

AS089515.ppt
 INDICATIONS -
FULLY EDENTULOUS
 Poor retention

 Functional disturbances

 Psychological disturbances

AS089516.ppt
MEDICAL EVALUATION

 Cardiovascular
 Respiratory
 Renal
 Musculoskeletal
 Neurological
 Endocrine
AS089517.ppt
SPECIFIC MEDICAL CONDITIONS

 Diabetes
 Coronary artery disease
 Alcoholism
 Drug therapy - anticoagulants
- anti epileptics
- antidepressants
- others
 Osteoporosis
 Smoking AS089518.ppt
 PSYCHE

 Perception of outcome
 hypercritical

 demanding

 unrealistic expectation

 Time and expense

 Aesthetics
 Maintenance
AS089519.ppt
 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
AS089520.ppt
 RADIOLOGY

 OPG
 Lateral Cephalogram
 Periapicals
 CT Scan - axial
- coronal
- 3D reconstruction
- Dentascan
 MR AS089521.ppt
 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 AS089522.ppt
 ALVEOLAR FORM

A Good alveolar ridge form

B Moderate residual ridge form
C Advanced resorbtion / Basal bone only
D Basal bone resorbtion
E Extreme resorbtion

AS089523.ppt
 BONE QUALITY
1 Mainly cortical plate compact bone
2 Thick compact bone with a dense
trabecular core
3 Thin cortical plate with dense trabecular
core
4 Thin cortical plate with low density
trabecular core
AS089524.ppt
BONE QUALITY

AS089525.ppt
 ANATOMY

 Mental nerve
 Inferior alveolar nerve
 Nasal cavity
 Maxillary antrum
 Incisive canal
 Soft tissues

AS089526.ppt
SURGICAL REQUIREMENTS

 Standardised surgical protocol

 Surgical environment
 Implant equipment - reusable
- disposable/single use
 Fully evaluated and prepared patient
 Trained staff

AS089527.ppt
EQUIPMENT
FIRST STAGE

AS089528.ppt
 STAINLESS STEEL

 Guide drill
 2mm twist drill
 Pilot drill
 3mm twist drill
 Countersink

AS089529.ppt
 TITANIUM

 Tap
 Implant
 Coverscrew

AS089530.ppt
ANAESTHESIA

 General
 Local
 Sedation

AS089531.ppt
 SURGICAL

 Aseptic technique
 Gentleness
 Precision

AS089532.ppt
SURGICAL PRELIMINARIES

 Induction of anaesthesia
 Endotracheal intubation
 Throat pack
 Scrub and gown
 Surgical preparation
 Draping
AS089533.ppt
AS089534.ppt
SURGICAL PROCEDURE
 Local Anaesthetic
 Try in stent
 Tattoo
 Surgical incision
 Flap reflection
 Flap retraction
 Try in stent AS089535.ppt
AS089536.ppt
AS089537.ppt
SURGICAL PROCEDURE
 Smooth ridge
 Use stent
 Guide drill
 Small twist drill
 Pilot drill
 Large twist drill
 Depth guide AS089538.ppt
AS089539.ppt
AS089540.ppt
AS089541.ppt
AS089542.ppt
AS089543.ppt
SURGICAL PROCEDURE

 Countersink
 Fixture insertion
 Cover screw
 Debridement
 Closure

AS089544.ppt
AS089545.ppt
AS089546.ppt
AS089547.ppt
AS089548.ppt
AS089549.ppt
AS089550.ppt
POSTOPERATIVE CARE

 Haemostasis
 Analgesia
 Antibiotic regime
 Chlorhexidine mouthwash
 Suture removal
 Temporary prosthesis
AS089551.ppt
 SECOND STAGE

 Soft tissue
 Bone removal
 Cover screw removal
 Healing abutment
 Replacement
 Dressings

AS089552.ppt
AS089553.ppt
AS089554.ppt
 KEY POINTS

 Implant positioning - bucco/lingual

- axial
- separation
 Drill speeds - 2000rpm
- 20rpm
 Torque
 Irrigation
AS089555.ppt
 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
AS089556.ppt
TECHNIQUE MODIFICATIONS

 Countersinking
 Self tapping implants
 Wide implants

AS089557.ppt
COMPLICATIONS WITH
OSSEOINTEGRATED
IMPLANTS

AS089558.ppt
 COMPLICATIONS
 Preoperative
 Perioperative
 Postoperative
 Transient
 Persistent
 Permanent
 Soft tissue
 Hard tissue
AS089559.ppt
SERIOUS COMPLICATIONS

 Jaw fracture
 Haemorrhage
 Ingestion
 Inhalation
 Neurological
 Death

AS089560.ppt
 COMPLICATIONS
 Patient selection
 Psyche
 Anatomy
 Systemic disease
 Implant factors
 Surgical
 Prosthodontic
 Errors in judgement
 Deviation from established protocol
AS089561.ppt
 ANATOMY

 Unsuitable morphologically
 Reduced bone density
 Reduced bone volume
 Attached tissue
 Nerve position

AS089562.ppt
PREVENTION OF NERVE
DAMAGE
 CT
 Bone density measurement
 Drill sleeves
 Discretion is better part of valour

AS089563.ppt
 COMPLICATIONS

Peroperative

 Failure to obtain anaesthesia

 Haemorrhage
 Stuck implant
 Loose implant
 Lost implant
AS089564.ppt
 SURGICAL FAILURE

 Poor planning
 Poor surgical technique
 Lack of precision
 Thermal injury
 Faulty placement
 Damage to adjacent structures

AS089565.ppt
 SURGICAL

 Haemorrhage
 Stuck implant
 Loose implant
 Lost implant

AS089566.ppt
 COMPLICATIONS

 Wound dehiscence
 Infection
 Mucosal perforation
 Fistula formation
 Anatomical - antral
- nasal
- neurological
AS089567.ppt
 STAGE ONE SURGERY

 Failure to obtain anaesthesia

 Faulty placement
 Anatomical
 Surgical

AS089568.ppt
 SURGICAL

 Stripped bone threads

 Exposed implant threads
 Fractured drill
 Sheared implant hex
 Excessive countersink
 Eccentric drill

AS089569.ppt
COMPLICATIONS

Second stage

 Loose implant
 Excess bone coverage
 Exposed threads
 Coverscrew problems

AS089570.ppt
 STAGE TWO SURGERY

 Wrong abutment length

 Faulty abutment seating
 Retained sutures
 Gingival hyperplasia
 Mobile tissue
 Destroyed cover screw hex
 Failure of integration
AS089571.ppt
 FAULTY PLACEMENT

 Labial / buccal
 Lingual
 Too close
 Straight line in mandibular anteriors
 Angulation
 Divergence
 Correct by use of a surgical template
AS089572.ppt
 POSTOPERATIVE

 Fascial space infections

 Haematoma
 Jaw fracture
 Sinusitis
 Wound dehiscence

AS089573.ppt
 WOUND DEHISCENCE

 Poor flap design

 Poor surgical technique
 Poor repair
 Poor tissue quality
 Previous surgery
 Underlying medical condition
 Superficial implant placement
AS089574.ppt
 PERSISTENT

 Neurological damage
 Aesthetics
 Speech
 Function
 Psychological

AS089575.ppt
 COMPLICATIONS
Long term
 Anatomical
 Neurological
 Deintegration
 Progressive thread exposure
 Gingivitis
 Hyperplastic tissue
 Fractured Implant AS089576.ppt
 PROSTHODONTIC
 Avoid premature loading
 Passive fit
 Good design
 Good oral hygiene
 Loss of integration
 Soft tissue problems
 Oral hygiene and maintenance
 Retrievable v cemented
AS089577.ppt
 COMPONENT FAILURE

 Fractured fixture
 Fractured abutment screw
 Fractured punch blade
 Fractured screw driver tip
 Fractured castings

AS089578.ppt
 MANAGEMENT OF
FAILURE

 Failing implants FAIL

 Removal
 Abandon
 Alternative site
 Larger diameter
 Replacement after healing

AS089579.ppt
GRAFTING TECHNIQUES

AS089580.ppt
 GRAFTING
Autogenous - Local
symphysis
third molar
angle
tuberosity
- Distant
rib
iliac crest
tibia
calvarial
Allogenic - frozen
- freeze dried
- demineralized AS089581.ppt
 BIOMATERIALS
- methyl methacrylate
- silicone
- proplast
- teflon
- calcium phosphates
- plaster of paris
- tricalcium phosphate
- hydroxyapatite
- goretex AS089582.ppt
 GRAFTS

 Autogenous bone
 Freeze dried bone
 Synthetic biomaterials

AS089583.ppt
 FREEZE DRIED BONE

 Commercial preparation
 Multiple donors
 Screened for HIV, Hep B and C
 Sterilised by irradiation
 Risk of prion borne disease
 Not licensed in Australia

AS089584.ppt
CALCIUM PHOSPHATES

 Plaster of paris
 Tricalcium phosphate
 Hydroxyapatite

AS089585.ppt
 INDICATIONS FOR
GRAFTING

 Anterior maxilla
 Posterior maxilla
 Anterior mandible
 Posterior mandible
 After resection
 Post traumatic

AS089586.ppt
 TECHNIQUES

 Cortico-cancellous blocks
 Trephined core
 Sinus Lift
 Vascularised bone flap

AS089587.ppt