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Biomaterials:
Biologically compatible materials that can be used for manufacturing of implants They include: A. Metals and metal alloys: most widely used material is titanium and its alloy B. Ceramics and carbons: aluminum oxide, carbon, carbon-silicon compound, and hydroxyapatite C. Polymers and composites: includes cross-linked polymers (silicone, rubber, polyethylene) not in general use at present.
The Implant Bone interface: 1.Osseointegration: - There is an absence of C.T. or any non bone tissue in the interface between the implant and the bone at the light microscope level. - Successful cases will have 30% and 95% of the implant surface in contact with bone. - After an initial remodeling in the first year that results in .9-1.6 mm of bone reduction, the bone level around healthy functioning implants remains stable. - Compact bone offers a much greater surface area for mineralized tissue- to implant contact than cancellous bone maxilla has lower success rates then mandible. 2.Fibro-osseous integration - In which soft tissue (fibers and/or cells) are interposed between the implant and the bone.
Clinical management
A.Appropriate selection of cases B.Adequate preparation of biomaterials C.Careful handling of patients soft and hard tissue
10. Soft tissue quality and quantity good keratinized, attached mucosa for better functional and aesthetic results for implant restoration
B Adequate preparation of biomaterials To achieve an osseointegrated implant with a high degree of predictability. The implant must be: 1. Sterile 2. Made of a biocompatible material 3. Inserted with an atraumatic surgical technique (heat) 4. Placed with initial stability 5. Not functionally loaded during the healing period of 4-6 months.
C- Careful handling of patients soft tissues 1. Aviod over heating of bone 2. Good handiling of soft tissues during suturing
systems world wide, many lack short and long data . Examples of implant systems with good clinical and experimental research are : 1- Nobel Biocare System 2- International Team for Oral Implantology (ITI) System 3- 3i ( Implant Innovations ) System 4- Astra dental Implant System
Nobel Biocare System developed by Branemark in sweden in the early 1960s - it is a machined pure titanium screw-shaped implant - Tiunite-------- TPS coating - SteriOss system --------Replace (tapered titanium implant which comes in an acidetched, TPS, HA coatin )
Intrnational Team for Oral Implant ( ITI ) System - developed in Switzeriand by Schroeder and colleagues in the early 1970s - it comes in different designs ( hollow cylinder, full-body screw ) - surface characteristic-----befor it was plasma-sprayed titanium coating, now it is sand-blasted, acid-etched surface - implant protrudes through the mucosa adva.------- no second surgery, disadva.----- 1- premature loading 2- danger of titanium showing in the marginal mucosal area
3i (Implant Innovations ) System - developed by Lazzara and Beaty in 1988 - it 1or 2-stage commercially pure titanium screw and cylinder implant with either an acid etched, TPS, HA coated surface - new implant------- rough middle and apical part ( for better bone integration ) and smooth coronal part ( for better maintenance properties )
Astra Dental Implant System - developed in the 1980s in Swedwn - it is a pure titanium screw shaped implant with an oxide-blasted coating - it comes with conical abutment that fits tightly into the coronal part of the implant
The Root form implants can be divided according to their : -I - body shapes (macrodesign) -II - surface topography (microdesign)
I Macrodesign
a) Threadless b) Threaded - Provide superior initial stability - In dense bone they need taping - Some are shaped conically to minimize apical bone fenestration - Good for in anterior immediate placement
II Microdesign - Textured surface (HA, TPS) - Provide secondary stability - If surface is exposed to oral fluid and microorganisms progressive bone loss - Smooth surface implant is more resistant to bacterial contamination and progressive bone loss but provides weaker secondary stability
Advantages of one-stage implant surgery 1-easier mucogingival management 2-patient comfort because surgeries are involved 3-esthetic management is easier
Recommendations for two-stage implant surgery 1-if there is extensive bone loss at the implant site 2-if vertical bone augmentation is necessary 3-if interproximal bone of the adjacent teeth is lacking
For both one and two-stage implant approach the implant should not be loaded for 2-3 months in the mandible and for 4-6 months in the maxilla
Placement of the implant 2 months after the extraction to allow for soft tissue healing
Advantages 1. Easier mucogingival management 2. We have more osteogeneis adjacent to the implant 3. Reduction of the treatment time 4. Allows time for resolution of infection from the extracted tooth
2. External
Implant Reconstruction 1. Fully edentulous arches A - Fixed (Screwed cemented) B - Overdenture (clips + bar) 2. Partially edentulous 1 - Single tooth 2 - Multiple teeth
Complications
1. Early onset (during the treatment phase) mobility after the healing period 2. Late onset (during the maintenance phase) mucosal inflammation, progressive bone loss and mechanical problem
Maintenance Phase
- Proper oral hygiene and appropriate occlusal forces are critical for long-term function of an implant prosthesis. - Recalls should be every 3 months for the first year, and then every 6 months - Evaluation of oral hygiene, occlusal harmony implant and prosthesis stability, overall soft and hard peri-implant tissue health, and radiographic follow up.
- Peri-implant
Pathologic changes of the peri-implant tissues - Peri-implant mucositis: inflammatory changes which are confined to the soft tissue surrounding an implant - Peri-implantitis: progressive periimplant bone loss in conjunction with a soft tissue inflammatory lesion. the over all frequency of periimplantitis is in the range of 5% to 10% - the mean crestal bone around an implant decreases 0.9 to 1.6 mm during the first year of implant function
disease:
Etiology
A.Bacterial infection B.Biomechanical factors C.Cofactors
A - Bacterial infection
Plaque accumulation of the implant surface subepithelial C.T becomes infiltrated by large number of inflammatory cells ulcerated and loosely adherent epithelium plaque migrates more apically clinical and radiographic signs of tissue destruction - Bacterial flora in adult periodontitis and peri-implantitis have great similarities - Bacterial flora in totally edentulous and partially edentulous mouth is different. Q: Why is the size of the soft tissue inflammation and bone loss greater around implants than around teeth? A: 1. Low vascularity soft tissue band around the implant 2. Difference in the collagen-to-fibroblast ratio of the gingival tissue (affects the defense mechanisms) 3. Implant surface characteristics (Hyroxyapatite coated implant vS. Titanium coated implants) -
B - Biomechanical Factors
- Excessive biomechanical forces that lead to high stress or microfractures in the coronal bone to implant contact which lead to less of osseointegration around the neck of the implant - The role of loading has increased influence in: 1. The implant is placed in poor-quality bone 2. Poor load distribution 3. Parafunction 4. The prosthetic superstructure does not fit the implants precisely.
C Co factors
1. Traumatic surgical techniques 2. Inadequate amount of host bone 3. Compromised host response 4. Smoking
(normal periimplant bone level is 1 mm apical to the position of the probe tip)
3. 4. 5. 6. 7. 8.
B Anti-infective therapy
1. Removal of plaque and polishing with high-pressure air powder abrasive ( sodium bicarbonate and sterile water ) 2. O.H. Re-inforcment 3. Subgingival irrigation of the peri-implant pockets with chlorhexidine 4. Systemic antibiotics for 10 days ( doxycycline and metronidazole )
C Surgical Therapy 1. Resective therapy To pocket + correct negative osseous architecture + the area of keratinized gingiva 2. Regenerative therapy to pocket with regeneration of lost bone tissue
Indications for Resective Therapy 1. Moderate to advanced horizontal bone loss 2. Moderate vertical bone defect ( < 3mm ) 3. One and two wall defects 4. Implant position in nonaesthetic area
Indications for Regenerative Therapy 1. Implant allows complete closure with flap 2. Moderate to advanced vertical defects 3. Two and three wall bone defects 4. Detoxification of implant surface possible
Indications for Implant Removal 1. Severe peri-implant bone loss (> 50%) 2. Unfavorable advanced bone defect (one wall) 3. Rapid, severe bone destruction (within 1 year of loading) 4. Non surgical or surgical therapy ineffective 5. Esthetic area precluding implant surface exposure
Surgical Aspects of Dental Implants At the end of the lecture, students should be able to: Know how to select suitable cases for implant cases therapy Know complications of implants and how to maintain implant patients Know the different techniques of endosseous implant surgeries Explain how to diagnose and treat peri-implant disease