Documente Academic
Documente Profesional
Documente Cultură
OF THE SYSTEM
osd 2001, Vol 12
The field of dental implantology increased rapidly until the beginning of the
last decade. This is explained not only by the increasing level of dentists’
knowledge and skills, but also by the various national social security systems in
Central Europe and some Scandinavian countries. Today, these systems are less
effective as a result of economic depression. This has forced the development
of reasonable, simplified and rational dental implant systems such as the Osfix
system.
Anatomical hand books were written a long time ago, therefore the idea of this
book is not to teach surgical anatomy. However, repetitio est mater studiorum.
It is not a waste of time to consider applied implantological anatomy, because a
small misalignment of an implant may result in tremendous technical problems
between the bone surface and occlusion becoming apparent. It is impossible to
overstate the importance of the advice of experienced implantologists and the
enormous knowledge which is available in other implantological books.
It may be that surgeons are born, i.e. surgical capability is mainly inherent,
not the result of academic education. If the implantologist has “good hands”
the bone tissue also “feels good”. Some details in the Osfix system may be at
odds with general implantological faith and might contradict accepted “facts”.
However, when the results are of a top-level European standard, it is a time to
reconsider. The philosophy of Osfix is 10 years old, today Osfix is a system for
which more and more references are available - scientific and clinical.
Risto M.Kotilainen
Author
INTRODUCTION OF THE AUTHORS:
Mr. Lappi, Timo: Dent. Tech., Production Manager - Part II, photographs in Part I
Mr. Luotio, Kari: DDS, PhD, Consultant Surgeon - Parts I and V, Senior Editor
Ms. Turunen, Jaana: Dental Hygienist. - Part III and follow-up study
The author would like to thank the above mentioned for their assistance in the
project to develop a new implant system. In addition, the author extends his
gratitude to everyone else who has participated in the process: performing their
graduation work for the company, colleagues giving professional advice and
financial support to the project.
ABBREVIATIONS:
Ag Silver
Au Gold
Cl Chloride
Cr Chromium
Co Cobolt
Nm Newton meter
Ti Titanium
CoCr / Au framework
with integral abutments
(custom made)
Prosthetic srews
(prefabricated)
Implants (prefabricated)
Support legs i.e. integral
abutments
Implants
Implants
MAIN MENU:
FOREWORD
ABBREVIATIONS
ESSENTIAL TERMS
PART I: Clinical........................................................... 9
Clinical guidelines
for surgery
and prosthodontics
Page - 10
PART I CONTENTS:
1. INTRODUCTION
1.1 The Osfix Dental Implant System - A brief review of
literature and presentation of the products.......15
1.1.1 Surgery .....................................................15
1.1.2 The prosthetic structure ............................16
1.1.3 Cobalt chrome as frame material .................16
1.1.4 Expected success rate ...............................16
1.1.5 Special techniques in surgery ......................17
1.1.6 Presentation of the product ........................18
1.2 The structure of Osfix and Biosfix implants.........19
1.2.1 Osfix .........................................................19
1.2.2 BiOsfix.......................................................20
1.3 The prosthetic superstructure..........................23
1.3.1 Totally osteointegrated prostheses .............23
1.3.2 Prostheses supported with osteointegration 24
1.4 Patient satisfaction .........................................24
1.5 Main solutions .................................................25
1.6 Components ....................................................26
5. EXAMPLES
5.1 Biosfix ............................................................63
5.2 Standard fixing bar ..........................................69
5.3 Totally fixed prosthesis ....................................73
5.4 Combination ...................................................76
5.5 Aesthetic problems .........................................79
6. FAILURES ..............................................................81
6.1 Loss of Implants ..............................................81
6.2 Mistakes in structural design ...........................81
6.3 Mistakes in fabrication .....................................81
6.4 Patient related factors.....................................81
Page - 14
1. INTRODUCTION YOU ARE IN:
PART I: Clinical
1.1 The Osfix Dental Implant System - A brief review of
literature and presentation of the products 1. INTRODUCTION
Page - 15
1.1.2 The prosthetic structure
The success rates of implants have, followed 2,023 implants placed into
over the years, become quite clearly a total of 974 patients. All prosthetic
defined. Scientific follow-up studies structures were represented from
on implants with a roughened surface single tooth implants to full dentures
structure hold a reasonably good completely fitted to the bone, and full
promise for the success of the prostheses supported with a bar. The
treatment. Fugatsotto et al. (1993) cumulative success rate at the end of
Page - 16
the 5 year follow-up study was 93 % for implantation process was good: of YOU ARE IN:
the maxilla and 96 % for the mandible. more than 1,000 implants, only 9
A study by Babbush and Shimura (1993) were lost at secondary surgery due to
PART I: Clinical
followed 1,059 implants placed in a inadequate integration. The remaining 1. INTRODUCTION
total of 322 patients; the final success 28 implants were lost during the 5 year
1.1 The Osfix Dental
rate in a 5 year follow-up was 96 %. follow-up period. This study confirmed Implant System -
A division of success rates between the implantologically accepted fact A brief review of
jaws gave a rate of 92 % for the that the longer and wider the implant, literature and
presentation of the
maxilla and 99 % for the mandible. the better the result. products
Thus the primary success rate of the
1.2 The Structure of Osfix
1.1.5 Special techniques in surgery and Biosfix implants
Page - 17
1.1.6 Presentation of the product
The Osfix implant is a cylindrical implant a bridge implant that enables the
with an apical screw portion for construction of dolder-type bar
improved primary stability. The implant structures to support the prosthesis.
has an internal hexagonal structure for The main differences between the
tightening during surgery. The implant Osfix implant and other existing
is made of grade 2 pure titanium and implants is the simplicity of the
the implant surface is mechanically structure, the low component count
coarsened. The upper section of the and the low price of the product.
implant is polished. The length of
the implants are 11.0 and 13.5 mm The base of the Osfix implant is
and the outer diameter 3.75 mm. The formed by the actual implant cylinder,
Osfix implant is primarily designed for which is fitted to the jawbone. This
use in bar retained over-dentures in is covered during the first operation
the lower jaw in totally edentulous with a primary screw. In a subsequent
patients, but many other indications operation, the screw is removed from
are valid, as described later. the implant cylinder and replaced by
an impression post, which is fitted into
Osfix implants are products made place with occlusal screws included
by Osfix International Ltd Oy. They in the set. The impression posts are
are friction fastened, mechanically then delivered to a dental laboratory
roughened implants in which primary where they are cast into part of the
stability has been increased with a superstructure.
threaded tip. The Osfix implant is
a minimun of three
OSFIX implants are
needed for each frame
structure
Page - 18
1.2 The Structure of Osfix and Biosfix implants YOU ARE IN:
1.2.1 Osfix PART I: Clinical
1. INTRODUCTION
The basic element of the Osfix implant bridge may not be built on one or
is a titanium implant cylinder equipped two implants, as rotational movement 1.1 The Osfix Dental
with an apical screw, which is fixed in of the bridge is an absolute Implant System -
A brief review of
the alveolar bone. The cover screw is contraindication in this system. For literature and
screwed onto the cylinder in the single crowns and short bridges, the presentation of the
first operation. In a subsequent Biosfix implant should be used, as it is products
impression procedure, the cover screw a single tooth implant supplied with a 1.2 The Structure of Osfix
is removed and a bridge construction rotation check or hexagon. and Biosfix implants
is made and fitted in place with
1.3 The Prosthetic
the prosthetic screws supplied by important The use of various alloys superstructure
Osfix. The prosthetic structure of Osfix is possible: The system
1.4 Patient satisfaction
differs from other systems in that the contains burn-out
Osfix implant is the first dental implant components for CoCr and 1.5 Main Solutions
system which has been designed to cast-on components for
1.6 Components
use cobalt chrome frameworks. gold and metal ceramics.
Machined titanium 2. OSTEOINTEGRATION
AND TITANIUM
A minimum of three Osfix implants components are also IMPLANTS
are needed for each frame structure. available to order.
3. PLANNING THE
It is important to understand that a
TREATMENT
4. THE PROCEDURES
5. EXAMPLES
6. FAILURES
Page - 20
YOU ARE IN:
Prosthetic variations of
BiOsfix is based on PART I: Clinical
important
BiOsfix:
cast-on components i. e.
- Cementation on custom 1. INTRODUCTION
metal ceramic crowns.
made abutment
Machined titanium 1.1 The Osfix Dental
- Screw retained crown Implant System -
components are available
A brief review of
to order. literature and
presentation of the
products
1.6 Components
2. OSTEOINTEGRATION
AND TITANIUM
IMPLANTS
3. PLANNING THE
TREATMENT
4. THE PROCEDURES
5. EXAMPLES
6. FAILURES
Page - 21
Only three parts:
Implant, crown
and screw
Page - 22
1.3 The Prosthetic superstructure YOU ARE IN:
1.3.1 Totally osteointegrated prostheses PART I: Clinical
1. INTRODUCTION
In the Osfix system, these are the occlusion forces fully correspond
constructed on a maximum of five or to those of natural teeth, whereas 1.1 The Osfix Dental
Implant System -
six implants in the bone, fitted with a the occlusion forces of an ordinary
A brief review of
metal framed, acrylated full denture: prosthesis are only 1/4 - 1/5 those of literature and
a chrome cobalt frame full denture natural teeth. Totally osteointegrated presentation of the
with acrylic teeth is fitted on the products
can take a cantilever in the maxilla up composite and metal frame. Ceramics
to 10 mm, and in the mandible up to are being tested in the Osfix system
20 mm. With this kind of prosthesis, but are not yet in clinical use.
Page - 23
1.3.2 Prostheses supported with osteointegration
Page - 24
1.5 Main Solutions YOU ARE IN:
PART I: Clinical
1. INTRODUCTION
1.6 Components
2. OSTEOINTEGRATION
AND TITANIUM
IMPLANTS
3. PLANNING THE
TREATMENT
4. THE PROCEDURES
5. EXAMPLES
6. FAILURES
OSFIX Components
OSFIX implants:
• ø 3.75 mm
• ø 2.8 mm
• ø 2.6 mm
1.6 Components
4. THE PROCEDURES
5. EXAMPLES
6. FAILURES
BiOsfix Copyposts:
PILOT-DRILL
STEP-DRILL L2
STEP-DRILL L6
STEP-DRILL S2
STEP-DRILL S6
counter-sink 4.2 mm
counter-sink 5.0 mm
scale 3:2
Page - 28
OSFIX and BiOsfix Instruments
scale 5:7 YOU ARE IN:
PART I: Clinical
1. INTRODUCTION
1.6 Components
2. OSTEOINTEGRATION
AND TITANIUM
IMPLANTS
3. PLANNING THE
TREATMENT
4. THE PROCEDURES
5. EXAMPLES
6. FAILURES
Page - 29
2. OSTEOINTEGRATION AND
TITANIUM IMPLANTS
2.1 Osteointegration
Page - 30
Key factors in osteointegration YOU ARE IN:
1. Grade 2 titanium of over 99 % Celsius, and the rotation speed of PART I: Clinical
purity. the drill must be below 2,000 rpm.
1. INTRODUCTION
2. An oxide layer forms on the 5. Two-phase surgery that allows 2. OSTEOINTEGRATION
titanium surface to which the osteointegration without AND TITANIUM
glyco-protein layer will attach and disturbance; the implant IMPLANTS
later calcify. structures will be subjected to 2.1 Osteointegration
strain only after the proper
3. The shape of the implant 2.2 Rejection of foreign
osteointegration period of 3-6 materials
distributes the occlusion stress
months.
evenly to the bone. A triple surface 2.3 Bone tissue
increase has been created in the 6. High asepsis in procedures.
2.4 Healing of bone after a
Osfix implant: the apical screw, the
7. The formation of a proper epithelial trauma
micro screw of the stem and the
integration in the second phase 2.5 Epithelial attachment
sand blasting on the surface of the
implant multiply its surface area. 2.6 Implants
6. FAILURES
Page - 31
Criteria for successful osteointegration
Page - 32
2.2 Rejection of foreign materials YOU ARE IN:
The antigen-antibody reaction will Connective tissue organisation or PART I: Clinical
reveal any alien proteins found in the encapsulation means that foreign
1. INTRODUCTION
living system. Corroding metal ions material in the system will be
will form complexes with the system’s surrounded with connective tissue. The 2. OSTEOINTEGRATION
AND TITANIUM
own proteins that are recognised thickness of the capsule will depend on
IMPLANTS
as antigenes. Therefore, titanium the material causing the reaction. With
implants must be kept clear of any the exception of titanium, practically 2.1 Osteointegration
saliva or foreign metal contamination. all materials are encapsulated in the 2.2 Rejection of foreign
The package efficiently protects the system. The movement of foreign materials
Osfix implant until the very moment material is known to enhance the 2.3 Bone tissue
it is placed in the bone, whilst the capsulation around it, therefore the
2.4 Healing of bone after a
cylindrical primary insertion gives primary fixation of the implant is
trauma
protection against contamination extremely important.
during the procedure. 2.5 Epithelial attachment
2.6 Implants
2.3 Bone tissue
3. PLANNING THE
Bone is structurally divided into dense bone is the biologically active TREATMENT
compact and spongious bone, or cell layer of the bone, made up of
4. THE PROCEDURES
dense and cancellous bone; chemically osteoblasts and osteoclasts. Their task
into organic and inorganic bone, each is to form new bone in the event of 5. EXAMPLES
of which amount to about 40 % of injuries. The outermost layer is the 6. FAILURES
the bone. The organic part consists periosteum which is attached to the
of collagen, glycosaminoglycans and bone by ligaments. PART II: Laboratory
osteonectin. The inorganic part is
PART III: Hygiene
almost entirely made up of hydroxyl The function of the bone is to act
apatite. both as a supportive structure and PART IV: Sedation
as a store for calcium. The exchange
The inside of the bone tissue is of calcium between blood and bone
PART V: Studies
cancellous bone formed by thin bony tissue is many tenfold compared to
lamellae. This trabecular architecture the normal calcium intake from food.
makes the structure of the bone lighter Most of the calcium stored in the
whilst maintaining its strength. This skeletal structure is firmly bound in
part of the bone contains the vascular the bone and balanced hormonally by
system while the dense bone carries parathormone and calcitonin.
no blood vessels. On the surface of the
Page - 33
2.4 Healing of bone after a trauma
Primary healing: The bone heals after thus reaching the final stage of this
a trauma when the fracture is clean healing process, when a pseudarthrosis
and full fixation is obtained. Blood or false joint is formed in the bone.
coagulates in the area with extensive
phagocytic activity during the first few Healing in the implantation
days. Thereafter, a procallus is formed procedure: Depending on the initial
and great numbers of fibroblasts can situation, any of the previous healing
be observed microscopically. When the processes may appear after the
connective tissue has become dense it implantation procedure. If secondary
is referred to as callus. This is where the healing takes place, the implant is finally
first osteoblasts appear. Following this, surrounded with pseudoperiodontal
maturation occurs or the osteogenic ligament corresponding to
fibres in the callus begin to calcify. pseudarthrosis. The final stage is called
Compact bone is formed initially, and fibrointegration. This type of healing
later it is organised into compact and can never produce long-lasting
spongy bone. Thus, the normal primary implantation, but if the implant is
healing of the bone has taken place. strained, fast resorption of bone
occurs, followed by infectious
Secondary healing: Secondary healing reactions, leading to the loss of the
is found in bone in cases of large, implant.
impure and comminuted fractures. No
stability is reached and the situation The result of primary healing after
is often complicated by infection. implantation is full osteointegration,
Granulation tissue and extensive in which the implant is joined directly to
infection forms in the area. This is the bone without any connective tissue
followed by delayed healing and a layer. It may be noted that the implant
vicious circle in which the infected is fully surrounded by compact bone
granulation tissue does not contribute which remains around the implant
to the creation of stability. Finally, after the well-timed introduction of
fibrous cartilage is formed in the area, loading.
Page - 34
2.5 Epithelial attachment YOU ARE IN:
In a natural tooth, the junctional to stop infection factors from reaching PART I: Clinical
epithelium is long and reaches right into the dentoalveolar junction.
1. INTRODUCTION
through the gingival enamel, up to
the enamel dentine. The epithelium A normal junctional epithelium is 2. OSTEOINTEGRATION
AND TITANIUM
ends its migration when it reaches formed against the mucosal piece of
IMPLANTS
the fibrous attachment structure of the implant. In successful implantation,
the tooth. The junctional epithelium when oral hygiene is good, a healthy
2.1 Osteointegration
shows continuous migration of cells connective tissue layer is, almost 2.2 Rejection of foreign
from the germinal layer up along the without exception, found under the materials
tooth surface, the epithelium cells epithelium, and thereunder begins 2.3 Bone tissue
finally scale off from the gingival unresorbed bone that is directly
2.4 Healing of bone after a
papilla. The purpose of this migration is connected to the implant.
trauma
2.6 Implants
2.6.1 Subdivision
3. PLANNING THE
Implants can be divided into chrome cobalt screw at the beginning TREATMENT
endodontal, subdermal, subperiosteal of the 60s. Acrylic was also tried as
4. THE PROCEDURES
and endosteal implants, of which a fixture material in those days, and
only the last mentioned will now be carbon-glass in the 70s. In its day, the 5. EXAMPLES
examined. popular Linkov’s plate was a success, 6. FAILURES
but reached only a 50 % success rate in
Endosteal dental implants are further long-term follow-up. The first implant PART II: Laboratory
divided into screw, plate and cylinder material with a 90 % success rate was
PART III: Hygiene
types. The materials used have been the ceramic developed in the 80s;
cobalt chrome, carbon, ceramics and aluminium oxide. The 90 % limit can, PART IV: Sedation
titanium. The first screw types were significantly, be surpassed only with
developed as early as the 1940s and the titanium implants. PART V: Studies
There are several titanium implant simply prepared models, such as Osfix.
systems available in Europe, from It must be remembered, though, that
various manufacturers. Almost all the implant adheres to the bone with
implant types based on titanium reach its surface. Therefore the prognosis
well over 90 % success rate in a for short and narrow implants is much
10 year follow-up. Cavity or thread poorer than that for long and wide.
preparations are extremely demanding Regardless of the make of implant,
procedures and this possibly accounts failures occur mainly with implants
for a lower success rate than with more shorter than 10 mm.
Page - 35
3. PLANNING THE TREATMENT
3.1 Indications
3.2 Contraindications
Page - 36
As a relative contraindication, it is often in charge of the radiotherapy. The YOU ARE IN:
mentioned that addiction to drugs, same applies to high blood pressure
alcohol or cigarettes can prevent the and diabetes. Neither of these systemic
PART I: Clinical
patient from following the restrictions diseases is an actual contraindication, 1. INTRODUCTION
during the first few days. Smoking if they are kept under control with
2. OSTEOINTEGRATION
is considered a risk factor in the medication. Consultation is AND TITANIUM
prognosis as it is. nevertheless needed whenever the IMPLANTS
patient has a fairly serious systemic
3. PLANNING THE
A radiation dose below 4,000 rad or the disease (ASA 3-4). TREATMENT
amount of secondary radiation should
3.1 Indications
always be discussed with the physician
3.2 Contraindications
5. EXAMPLES
replacement 6. FAILURES
The advantage of the treatment is the increase in oxygen content in the tissue of
hypoxic bone, and the following restoration of the vascular system in the radiated
tissue. Thus the injury reparation mechanisms are normalised in the tissue. For the suc-
cess of the implantation, the advantages of hyperbaric oxygen treatment are obvious,
as the implants would otherwise mostly be lost. After hyperbaric treatment, the success
rate is increased to that of ordinary implantations. The treatment can be performed
only in certain central hospitals.
Page - 37
3.3 Diagnosis and examinations needed
Page - 38
The first group always qualifies for Dental history includes earlier YOU ARE IN:
operation. For groups 2 and 3 it procedures: fillings, periodontics,
is recommended that some form extractions, surgery or possible
PART I: Clinical
of sedation be used during the occlusal therapy. 1. INTRODUCTION
procedures, and for groups 3 and
2. OSTEOINTEGRATION
4 there also has to be a vascular Clinical examination concentrates on AND TITANIUM
connection, the ability to monitor obtaining a full oral status. Plaster IMPLANTS
vital functions (preoperative EKG and model analysis of the relation of jaws,
3. PLANNING THE
preoperative pulse oximeter) and a anterior and lateral photograph of TREATMENT
professional emergency specialist, the patient’s face as well as intraoral
3.1 Indications
such as an anaesthetist, present during photograph might also be useful.
the procedures. The treatment of 3.2 Contraindications
group 4 patients should be avoided 3.3 Diagnosis and
with implantological implications, or examinations needed
if treatment is chosen, it should take
3.4 Placing the implants
place in a unit corresponding to
hospital conditions. 4. THE PROCEDURES
5. EXAMPLES
6. FAILURES
Page - 39
The most important examinations maxilla, the above mentioned
are nevertheless radiological radiographs are quite sufficient. On the
examinations or orthopantomog- other hand, transversal tomograms
ram, which is always needed. A are invaluable in the implantation
lateral skull radiograph will show of the posterior of the mandible, as
the relation of jaws and is valuable well as a fully edentulous maxilla.
when the prosthesis structure is When placing single implants in the
being planned. When implanting in premolar section of the maxilla, it
the anterior of an edentulous mandible is important to define the shape of
or the anterior of a partly edentulous the sinus and this is best done with
tomography.
Page - 40
3.4 Placing the implants YOU ARE IN:
3.4.1 Maxilla PART I: Clinical
1. INTRODUCTION
Typical for the maxilla is a small the area of premolars. At the edge
of premolars, the sinus already limits 2. OSTEOINTEGRATION
total amount of bone and high ratio
AND TITANIUM
of spongious bone. The placing of the length of implants, while the
IMPLANTS
the implants is further restricted by molar section can rarely be considered
without a sinus lift operation which 3. PLANNING THE
maxillary sinuses, the nasal cavity and
TREATMENT
incisive canal as well as the millary joint has not been studied with the Osfix
i.e. palatal suture. The best site for implant. 3.1 Indications
a long vertical implant is the canine 3.2 Contraindications
tooth area between the nasal cavity The optimal placing of Osfix implants
3.3 Diagnosis and
and maxillary sinus. Besides these two in the maxilla is as follows:
examinations needed
implants, there is usually room for
15-14 (inclined), 3.4 Placing the implants
four other implants, one pair vertically
under the nasal cavity and another 4. THE PROCEDURES
behind the long implants roughly in 13, 11, 21, 23,
5. EXAMPLES
Page - 41
3.4.2 Mandible
The best area for implants in the can be obtained when there is room
mandible is the anterior area between between the mental foramina for:
the mental foramina, if this area
contains ca. 10 mm of bone, it Six 11 mm long Osfix implants,
is sufficient for implantation. When
placing the implants in the mandible, Five or six 13.5 mm long Osfix implants,
it should be remembered that the or
mandibular canal makes an anterior
loop just before reaching the surface, Four or five 16 mm long implants
and therefore the implant cannot be (BiOsfix).
placed directly adjacent to the mental
foramens. The molar area of the The basic solution in the mandible for
mandible may be used for implantation Osfix implantation is, almost without
if there is ca. 11 mm of bone above exception, five 13.5 mm long implants,
the mandibular canal. of which the outermost pair is placed
at the foramen mentale with the apical
The sharp crestal area of the mandible head inclined towards the median line;
makes the planning of implant the middle implants in the median line
treatment more complicated, as it of the mandible and one pair between
has to be excised when installing the two others (thus forming a fan
the implant. It also has to be noted shape):
that the orthopantomograph is greatly
enlarged (horizontally 50-70 %, 44 (inclined),
vertically 10-30 %). The best result
43-42, 41-31, 32-33,
34 (inclined)
Page - 42
YOU ARE IN:
PART I: Clinical
1. INTRODUCTION
2. OSTEOINTEGRATION
AND TITANIUM
IMPLANTS
3. PLANNING THE
TREATMENT
3.1 Indications
3.2 Contraindications
4. THE PROCEDURES
5. EXAMPLES
6. FAILURES
Page - 43
In cases of bar constructions, 3 or 4 distal implants should be inclined to
implants are used. Three implants are allow sufficient space for the riders of
valid in resorbed bone cases and four the denture.
in non-resorbed cases. However the
Page - 44
YOU ARE IN:
PART I: Clinical
1. INTRODUCTION
2. OSTEOINTEGRATION
AND TITANIUM
IMPLANTS
3. PLANNING THE
TREATMENT
3.1 Indications
3.2 Contraindications
4. THE PROCEDURES
5. EXAMPLES
6. FAILURES
Page - 45
3.4.3 The mutual placing of implants
The placing of the implants should also be noted that Osfix implants are
allow enough bone to be left between always placed in a fan shape, avoiding
the implants. A rule of thumb would be parallel implantation. The fan may be
to leave a minimum of one implant’s divergent or convergent, but the space
width of bone: when 3.75 mm implants needed by impression posts should be
are used, ca. 4 mm bone should be borne in mind.
left between the implants. It should
Page - 46
3.4.4 The superstructure YOU ARE IN:
The superstructure i.e. prosthesis must and to think of the torsional forces PART I: Clinical
be considered during the implantation of occlusion on the structure i.e.
1. INTRODUCTION
phase. This means making sure the lever arms. A rule for cantilevers in
implants are not parallel, to ensure the superstructure is, at a maximum, 2. OSTEOINTEGRATION
AND TITANIUM
the maximum security for the the last implant’s length. It must be IMPLANTS
superstructure. remembered, however, that the bone
3. PLANNING THE
structure of the maxilla is weaker
TREATMENT
The problems caused laterally by the than that of the mandible. Therefore
occlusal relationship of the jaws should cantilevers in the maxilla must be 3.1 Indications
also be taken into account. A good smaller than the length of the last 3.2 Contraindications
method of predicting the restrictions implant while in the mandible it may
3.3 Diagnosis and
in jaw relations is to draw the be a little longer. In practice, the
examinations needed
placement of the implants and the cantilevers may not exceed 20 mm in
prosthetic structure on a lateral x-ray, the maxilla or 10 mm in the mandible.
3.4 Placing the implants
4. THE PROCEDURES
5. EXAMPLES
6. FAILURES
Page - 47
3.4.5 Partial prostheses or short bridges
The outer compact layer of bone may Totally fixed prostheses cannot be
be thin or thick, whilst spongious fabricated in a strongly resorbed
bone may be loose or dense. This mandible, but overdentures supported
grading alone offers four variations. by two, or preferably four, implants
The resorption in the bone may be should be used. In such cases, the
slight, medium or strong. When this fastening of the overdenture to the
factor is taken into account, we implant uses the mesiostructure i.e.
face 12 different variations, each the Osfix bar. Dalbo-type fasteners
posing an individual implantation should not be used, as they would
problem. Therefore, the quality of place considerably greater occlusional
the bone should always be graded and torsional forces on the implants
before implantation. The best bone compared to bar structures. It is
for implantation is slightly resorbed, extremely rare to find a patient with
with a dense spongy bone. A poor insufficient bone in the mandible for
one is a strongly resorbed bone with a an overdenture solution. In the maxilla,
thin compact layer and a loose spongy an implant supported overdenture is
bone. not a good solution, as the thickness of
the structures often severely disrupts
speaking.
Page - 48
YOU ARE IN:
PART I: Clinical
1. INTRODUCTION
2. OSTEOINTEGRATION
AND TITANIUM
IMPLANTS
3. PLANNING THE
TREATMENT
3.1 Indications
3.2 Contraindications
4. THE PROCEDURES
5. EXAMPLES
6. FAILURES
Page - 49
4. THE PROCEDURES
• Examinations • Impression
Personnel: Before the start of the and surgical gown. The implantation
implantation operation, all instruments procedure practically always requires
must be sterilised. The elimination another nurse or an non-sterile or
of the patient’s own flora must be circulating assistant to open the
ensured. The easiest way to do this implant cases and pass the sterile
is to make the patient wash his own contents to the surgeon.
face with a Hibiscrub® (chlorhexidin)
skin wash, and rinse his mouth with a Room: When considering the
Corsodyl® (also chlorhexidin) solution. suitability of an ordinary consulting
After this, and before any other room for implant surgery, the following
preparations, the patient’s blood points should be considered:
pressure is measured. Blood pressure
1. The microbiological purity of the
should also be measured after the
air conditioning and ventilation
procedure, and results recorded (also
system
note the points mentioned on the
patient’s eligibility for operation). 2. How well the floor can be cleaned
Before draping, the nurse will carefully
3. Sufficient light that can be
cleanse the skin with alcohol. The
correctly directed under sterile
drapes should be large enough to
conditions
ensure that no contamination is
transferred accidentally from the 4. Whether the suction system gets
surfaces of the operating theatre to blocked when accumulated blood
the sterile area. The outfit of the begins to coagulate in the tubes
surgeon and the primary assistant
5. The drill and engine should
includes bonnet, masks, sterile gloves
be powerful enough, and the
Page - 50
handpiece able to be sterilised
YOU ARE IN:
PART I: Clinical
1. INTRODUCTION
2. OSTEOINTEGRATION
AND TITANIUM
IMPLANTS
3. PLANNING THE
TREATMENT
4. THE PROCEDURES
5. EXAMPLES
6. FAILURES
Page - 51
6. The room should have enough remembered, however, that the hot
space for possible reorganisation air cabinet usually blunts the edges
of the cutting instruments. Therefore
7. Mobile equipment units facilitate
the autoclave is always used for
organisation
these. Small instruments such as extra
8. It must be possible to monitor the drills should be wrapped in double
vital functions of a fully covered sterilisation packages to ensure easier
patient with automatic equipment handling in case they are needed
e.g. with a pulse oximeter during the procedure. Bowls should
be placed in the autoclave on edge
Instruments: The cleaning to prevent cold air remaining at the
programme for the correct surgical bottom of the bowl.
instruments includes three steps:
On the day of the operation, the
1. Soaking in a phenolic detergent
operating room must be carefully
solution that dissolves the proteins
cleaned and washed with a
contaminating the instruments
disinfectant. Sufficient drape material
(e.g. in a dish-washing machine)
should always be secured. It can be
2. Rinsing with alcohol to dissolve the obtained ready sterilised or as non-
final remaining fats (e.g. slightly sterile “sheets“ that can be sterilised
denatured alcohol is sprayed on in the autoclave.
the instrument basket)
3. Autoclave sterilisation
Page - 52
• fast (1:1 or 1:2) straight handpiece • Osfix drill kit or sufficient cannon YOU ARE IN:
with fastening for external cooling drills
water
• implants PART I: Clinical
• a speed reduced hand piece (e.g.
Micro-Mega® 20 IMK, 1,500 rpm • tapping instruments 1. INTRODUCTION
with a contra-angle head with • turning tools (ratchet and torque
internal cooling) 2. OSTEOINTEGRATION
tap) AND TITANIUM
• suction tube with a plastic edge • antibiotic eye ointment IMPLANTS
• gauze folds, suture material (Terracortril®)
3. PLANNING THE
TREATMENT
4. THE PROCEDURES
5. EXAMPLES
6. FAILURES
Page - 54
When all implant sites have been YOU ARE IN:
finished, the implants are placed and
tapped into place. PART I: Clinical
1. INTRODUCTION
2. OSTEOINTEGRATION
AND TITANIUM
IMPLANTS
3. PLANNING THE
TREATMENT
4. THE PROCEDURES
5. EXAMPLES
6. FAILURES
Page - 55
Page - 56
YOU ARE IN:
PART I: Clinical
1. INTRODUCTION
2. OSTEOINTEGRATION
AND TITANIUM
IMPLANTS
3. PLANNING THE
TREATMENT
The insertion screws are removed and
4. THE PROCEDURES
the apical screw will now benefit from
the use of a hex wrench to screw the 4.1 Surgery - primary
operations
implants even deeper into their holes
i.e. implants are turned with a ratchet 4.2 Secondary operations
to their final depth. The implants are 5. EXAMPLES
placed to allow the upper edge to
6. FAILURES
remain slightly below the edge of
the bone and the 1.5 mm thick
PART II: Laboratory
primary cover screw to remain ca.
0.5-1 mm above the edge of the bone. PART III: Hygiene
Medical ointment (Terra-Cortril-P®,
Pfizer, Brussels, Belgium, eye/ear
PART IV: Sedation
ointment) is applied to the threaded PART V: Studies
hole at the marginal end of the implant,
and the cover screw is screwed into
place. The area is carefully rinsed and
the wound is closed with continuing
sutures. If sutures are resorbable
(catgut) they are not removed during
the healing period.
Page - 57
Two types of cover screws are available i. e.
flat (1.0 mm) and normal (1.5 mm)
Page - 58
4.1.4 Postoperative treatment of the patient YOU ARE IN:
After the procedure, the patient should is spread on the prosthesis’ base PART I: Clinical
be given time to rest at the surgery and placed in the patient’s mouth.
1. INTRODUCTION
before leaving, and he should leave A suitable timing for the second, i.e.
with an escort whenever sedation impression, operation is 3-6 months 2. OSTEOINTEGRATION
AND TITANIUM
has been used. The patient is given from the initial operation.
IMPLANTS
a prescription for antibiotics and
analgesics. The prosthesis is thinned The exposure of the cover screw during 3. PLANNING THE
TREATMENT
sufficiently so as not to strain the the healing period is quite common
possibly protruding implants. The and causes very few real problems. 4. THE PROCEDURES
prosthesis is fitted in place and a Instructions for cleaning are essential; 4.1 Surgery - primary
good fit is secured. Later, a soft other actions are mostly harmful. operations
relining material (Viscogel® or Ufigel®)
4.2 Secondary operations
6. FAILURES
4.2.1 Impression phase
The procedure begins with infiltrating PART II: Laboratory
local anaesthesia to the mucosa over
PART III: Hygiene
the implants. A small incision along the
crista is made at each implant head. The PART IV: Sedation
cover screws of the exposed implants
are removed with a screwdriver or PART V: Studies
a round-headed spatula. Impression
posts are screwed into the threaded
hole of the implant, and an impression
is taken using routine closed tray
methods. In the case of a bar retained
denture, it is recommended to remove
acrylic lingually from the prefabricated
new prosthesis at the location of the
impression posts so that the prosthesis
does not touch the posts when fitted.
The base of the prosthesis is filled with
impression silicone and the prosthesis
is pressed on for the patient to bite
the new prosthesis together to ensure
correct occlusion.
Page - 59
Once the impression material has
hardened, the tray/prosthesis is
removed. The quality of the impression
is tested by placing an impression
post in each hole and testing for
movement by hand. The impression is
sent to the dental laboratory where the
impression is equipped with laboratory
pieces and cast in plaster. The cover
screws are returned to the implants
or replaced by a healing set, and the
wound is closed normally.
Different impression
posts are available
Page - 60
4.2.2 Mounting the prosthetics YOU ARE IN:
Once the retention bar or other untightened screw. This will take 1-5 PART I: Clinical
prosthetic has been completed, the days. Thereafter, tighten all of the
1. INTRODUCTION
implants are located with the help of screws and the last one should now fit
the bar/frame: minimal openings are without any problems. 2. OSTEOINTEGRATION
AND TITANIUM
made, the cover screws are removed
IMPLANTS
and the bar is pressed firmly in place
so that the implant heads are clearly 3. PLANNING THE
TREATMENT
seen to rub against the metal bar. (If
the healing set has been used during 4. THE PROCEDURES
the healing period, the procedure is
4.1 Surgery - primary
somewhat simpler.) It is important operations
that the frame fits well against the
4.2 Secondary operations
implants, since due to the non-parallel
implantation of the Osfix implant 5. EXAMPLES
system, the frame must not be forced The prosthetic screws are tightened
6. FAILURES
into place by tightening the prosthetic after one week because the structure
screws. The spaces between the and design of the Osfix system makes PART II: Laboratory
prosthetic screws and the bar retention it almost impossible to secure the
proper adjustment the first time.
PART III: Hygiene
are sealed with an antibiotic steroid
After tightening and regreasing the
ointment (Terra-Cortril-P©, Pfizer, PART IV: Sedation
Brussels, Belgium). If some of the screws with Terra-Cortril-P©, they are
screws do not fit at the first covered with light-cured composite. PART V: Studies
appointment, do not try to force them The occlusion and fit of the denture
in place because of the risk of thread are checked and minor adjustments
damage. Leave the patient to “eat“ made to assure stability and optimal
the structure in place without the function.
Page - 61
The framework is fabricated using burn-out or cast-on components.
5. EXAMPLES
5.1 Biosfix
5.4 Combination
6. FAILURES
Page - 63
A pilot drill is used to enlarge the hole
to approx. 3.5 mm. The final drill is
then placed and intruded until the
counter-sunk portion is partly inside
the bone. The implant is removed
from its container using haemostats
(mosquitoes) and placed into the
socket with the same instrument. The
implant is pushed inside with a finger
or it may be carefully tapped in using
a mallet and tapping pin.
Page - 64
YOU ARE IN:
PART I: Clinical
1. INTRODUCTION
2. OSTEOINTEGRATION
AND TITANIUM
IMPLANTS
3. PLANNING THE
TREATMENT
4. THE PROCEDURES
5. EXAMPLES
5.1 Biosfix
5.4 Combination
6. FAILURES
Page - 65
After removing the insertion screw, a
ratchet is used to tighten the apical
threads. Finally, the cover screw is
attached and the wound closed with
e.g. catgut sutures.
Page - 66
After second stage surgery and YOU ARE IN:
impression taking, the crown, which
has integrated rotation control PART I: Clinical
(prosthetic cast-on component) and a 1. INTRODUCTION
prosthetic screw, is delivered from the
2. OSTEOINTEGRATION
dental laboratory. The healing post is AND TITANIUM
removed and ... IMPLANTS
3. PLANNING THE
TREATMENT
4. THE PROCEDURES
5. EXAMPLES
5.1 Biosfix
5.4 Combination
6. FAILURES
Page - 67
the crown is placed into the implant.
The prosthetic screw is tightened with
a torque-limiting hand-piece or with a
ratchet. The ratchet must always used
for the final tightening to 30-40 Nm.
Page - 68
5.2 Standard fixing bar YOU ARE IN:
Page - 69
The base of the prosthesis is filled with
impression silicone and the prosthesis
is pressed on for the patient to bite the
new prostheses together to ensure
correct occlusion.
Page - 70
YOU ARE IN:
PART I: Clinical
1. INTRODUCTION
2. OSTEOINTEGRATION
AND TITANIUM
IMPLANTS
3. PLANNING THE
TREATMENT
4. THE PROCEDURES
5. EXAMPLES
5.1 Biosfix
5.4 Combination
6. FAILURES
Page - 71
Once the retention bar or other
prosthetic has been completed, the
implants are located with the help of
the bar/frame: minimal openings are
made, the cover screws are removed
and the bar is pressed firmly in place
so that the implant heads are clearly
seen to rub against the metal bar. It
is important that the frame fits well
against the implants, since due to the
non-parallel implantation of the Osfix
implant system, the frame must not
be forced into place by tightening the
prosthetic screws.
Page - 72
After regreasing and retightening, one YOU ARE IN:
or two weeks later the openings above
PART I: Clinical
the screw slots are closed with normal
light-curing filling composite. 1. INTRODUCTION
2. OSTEOINTEGRATION
AND TITANIUM
IMPLANTS
3. PLANNING THE
TREATMENT
4. THE PROCEDURES
5. EXAMPLES
5.4 Combination
6. FAILURES
Page - 73
Impression posts are screwed into
place. Impression taking by both the
normal closed tray method and regular
silicon techniques are performed.
Page - 74
The procedure for a lower jaw YOU ARE IN:
prosthesis is quite similar to that
PART I: Clinical
for the upper jaw, but the use of
a low-speed hand-piece is almost 1. INTRODUCTION
unavoidable because of the oral 2. OSTEOINTEGRATION
angulation of the implants and the AND TITANIUM
reduced space in the mouth. However, IMPLANTS
the hand-piece must not be used 3. PLANNING THE
for the final tightening of the screw TREATMENT
unless the equipment is fitted with 4. THE PROCEDURES
a torque control system, but instead
5. EXAMPLES
the ratchet and screwdriver must be
used. 5.1 Biosfix
5.4 Combination
6. FAILURES
Page - 75
5.4 Combination
Page - 76
In the laboratory, a model is cast and YOU ARE IN:
cast-on prefabricated components
PART I: Clinical
fixed onto the implant analogues.
Then the normal wax-up procedure 1. INTRODUCTION
for metal ceramics is performed and 2. OSTEOINTEGRATION
cast using precious metal alloy. AND TITANIUM
IMPLANTS
3. PLANNING THE
TREATMENT
4. THE PROCEDURES
5. EXAMPLES
5.1 Biosfix
5.4 Combination
6. FAILURES
Page - 77
The three piece bridge on the
model…
Page - 78
5.5 Aesthetic problems YOU ARE IN:
PART I: Clinical
How to solve aesthetic problems if
the implants are placed protruding 1. INTRODUCTION
buccally? 2. OSTEOINTEGRATION
AND TITANIUM
-Cut the prosthetic screws and IMPLANTS
support-legs (integral abutments) to 3. PLANNING THE
the gingival level. If composite for TREATMENT
normal fillings are placed on the 4. THE PROCEDURES
openings, the aesthetics of the gingival
5. EXAMPLES
margin is limited. However, this
procedure is acceptable on palatal 5.1 Biosfix
openings when lip support is
5.2 Standard fixing bar
adequate.
5.3 Totally fixed prosthesis
5.4 Combination
6. FAILURES
Page - 79
To achieve a better result, laboratory
composite (Sinfony ®, Espe, Germany)
is used. Initially, the gingival margin is
built up with pink composite.
Page - 80
6. FAILURES YOU ARE IN:
During the impression, casting the glue, into the impression. Thus, whilst 6.3 Mistakes in fabrication
model or framework, mistakes are also casting the model, one or more posts 6.4 Patient related factors
possible: The most frequent failure is detached by the vibration. This is
during impression taking is that the visible in the framework as a vertical PART II: Laboratory
impression post moves, i.e. it is not error. The final type of laboratory
PART III: Hygiene
stable in impression silicone. This failure is a horizontal error which is
causes an angulation failure between caused by a poorly controlled casting PART IV: Sedation
the implant and the framework procedure. Thus the casting procedure
extension. The commonest mistake in must be calibrated in every laboratory PART V: Studies
dental laboratories is that the posts as described in the laboratory manual,
have not been fixed properly, with part II.
Page - 81
REFERENCES success and failure rates of 2,023
implant cylinders up to 60+ months
Adell R, Lekholm U, Rockler B,
in function. Int J Oral Maxillofac
Brånemark P : A 15-year study
Implants 1993 : 8 : 617-21.
of osseointegrated implants in the
treatment of the edentulous jaw. Int J
Geis-Gerstorfer J, Weber H, Sauer
Oral Surg 1981: 6 : 387-416.
K-H : In vitro substance loss due
to galvanic corrosion in Ti implant /
Albrektsson T, Zarb C, Worthington P,
Ni-Cr. supraconstruction systems. Int
Eriksson A : The long-term efficacy
J Oral Maxillofac Implants 1989 : 4 :
of currently used dental implants:
119-123.
A review and proposed criteria of
success. Int J Oral Maxillofac Implants
Haider R, Watzek G, Plenk H : Effects
1986 : 1 : 11-25.
of drill cooling and bone structure on
fixation. Int J Oral Maxillofac Implants
Babbush C, Shimura M : Five-year
1993 : 8 : 83-91.
statistical and clinical observations
with the IMZ two-stage
Hertel R, Kalk W : Influence of the
osteointegrated implant system. Int
dimensions of implant superstructure
J Oral Maxillofac Implants 1993 : 8 :
on peri-implant bone loss. Int J
245-53.
Prosthodont 1993 : 6 : 18-24.
Page - 82
Luotio K, Petrelius U : An optional Stenberg T : Release of cobalt from YOU ARE IN:
method for elevation of the mucous cobalt-chromium alloy construction in
membrane of maxillary sinus and oral cavity of man. Scand J Dent Res
simultaneous bone augmentation i.e. 1982 : 90 : 472-479.
sinus lift during dental implant
surgery (in Finnish). Perfis 1994 : 1: Watanabe F, Tawada Y, Komatsu
34-6. S, Hata Y : Heat distribution in
bone during preparation of implant
Luotio K : IMZ- and Frialit-2 implants sites: heat analysis by real-time
(in Finnish) The Finnish Dentists’ thermography. Int J Oral Maxillofac
Journal 1997 : 7: 356-362. Implants 1992 : 7 : 212-9.
Page - 83
Page - 84
PA R T II
L A B O R AT O R Y
the manual
Page - 86
1. INTRODUCTION
1.1 Osfix manual ....................................................89
1.2 Osfix implant system........................................89
1.3 Osfix dental treatment .....................................89
1.4 The main differences between Osfix
implants and other implant systems ..................90
1.5 Laboratory components and instruments...........90
5. BRIDGE
5.1 Waxing-up the framework ..................................96
5.2 Spruing............................................................96
5.3 Finishing the framework ....................................96
5.4 Building-up the acrylic teeth ..............................96
5.5 Keypoints.........................................................96
The manual describes, step by step, the construction of a 1.3 Osfix dental treatment
bar retained overdenture, a bridge and a fixed full arch
1.4 The main differences
bridge for which burn-out components are used. If cast-on
between Osfix implants
components are used, the technical protocol follows general and other implant
implant prosthetic principles, and the advices of this part are systems
only trendsetting. 1.5 Laboratory components
and instruments
Page - 89
1.4 The main differences between Osfix implants and
other implant systems
Page - 90
2. CALIBRATION OF CASTING YOU ARE IN:
PROCESS IN DENTAL PART I
LABORATORIES PART II
7. DISINFECTION OF THE
COMPLETED WORK
PART III
PART IV
PART V
Page - 91
3. PREPARATION OF MASTER
MODEL
• Screw laboratory analogues to • Remove impression posts.
impression posts. • Cut the impression into sections to
• Add a drop of glue to the body of check the fit of the posts.
impression post.
Fix the model in the articulator.
• Place impression posts in the
impression.
• Cast the impression in stone.
4. BAR RETAINED
OVERDENTURE
4.1 Preparation of the denture for impression taking
• When preparing the lower denture, • Send the denture to the dentist.
reduce the lingual area of the • Returned denture with impression.
denture to allow space for
• Cast the impression in stone.
impression posts and impression
• Place burn-out cylinders on occlusal
material.
screws and retain in place.
• Reinforce the prosthesis with cold
curing acrylic resin.
Page - 92
4.2 Waxing-up the bar YOU ARE IN:
• Join the acrylic bar pattern to the PART I
burn-out cylinders with wax.
PART II
• Cut the burn-out cylinders to the
1. INTRODUCTION
required height.
2. CALIBRATION OF
Recommendation: The position of the CASTING PROCESS
round bar should be parallel to the IN DENTAL
occlusal level and condylar axis. LABORATORIES
3. PREPARATION OF
The supra-gingival height of the bar is MASTER MODEL
1.5-2.0 mm.
4. BAR RETAINED
OVERDENTURE
4.3 Spruing
4.4 Finishing
4.6 Keypoints
5. BRIDGE
2.8 mm
2.6 mm
Page - 94
4.5 Acrylic work YOU ARE IN:
• Check the fit of the denture. PART I
• Attach the bar to the model and
position the riders. • Rebase the denture with cold curing PART II
acrylic resin and strengthen with
• Block-out with wax all but the 1. INTRODUCTION
fibre if necessary.
retaining parts of the riders and
• Finish the denture. 2. CALIBRATION OF
retention wire.
CASTING PROCESS
• Isolate the model. IN DENTAL
LABORATORIES
4.3 Spruing
4.4 Finishing
4.6 Keypoints
5. BRIDGE
7. DISINFECTION OF THE
COMPLETED WORK
PART III
PART IV
PART V
Page - 95
5. BRIDGE
5.1 Waxing-up the framework
5.2 Spruing
• Sprue, invest and cast following
normal practice in bridge work (see
calibration).
5.5 Keypoints
• The screw cylinders are filled with • Equal distribution of bite force to all
investment material. implants.
Page - 96
6. FIXED FULL ARCH BRIDGE YOU ARE IN:
PART I
6.1 Setting-up teeth
PART II
• Try to set-up teeth so that there is • Leave enough space for the bar.
1. INTRODUCTION
space for the occlusal screws in the • Take an index of the set-up.
lingual area of the denture. 2. CALIBRATION OF
• Boil-out the wax. CASTING PROCESS
IN DENTAL
LABORATORIES
3. PREPARATION OF
MASTER MODEL
4. BAR RETAINED
OVERDENTURE
5. BRIDGE
5.2 Spruing
5.5 Keypoints
6.6 Keypoints
7. DISINFECTION OF THE
COMPLETED WORK
PART III
PART IV
PART V
Page - 97
6.3 Spruing
Page - 98
6.6 Keypoints YOU ARE IN:
PART II
Occlusion area: the distance of the point where the construction carries
1. INTRODUCTION
furthermost contact point from the the maximal load of horizontal force.
most labial implant is the same as the 2. CALIBRATION OF
distance of the last contact point from A=B CASTING PROCESS
IN DENTAL
the last implant, though max. 10 mm. LABORATORIES
C=D (max 10 mm in upper jaw max 20
Defining the occlusal centreline = the
mm in lower jaw) 3. PREPARATION OF
MASTER MODEL
4. BAR RETAINED
OVERDENTURE
5. BRIDGE
6.3 Spruing
6.6 Keypoints
D
7. DISINFECTION OF THE
COMPLETED WORK
PART III
6.6.2 Gingival margin PART IV
PART V
Some space between the acrylic base dental floss, and in the lower jaw, an
and the gingiva is needed for cleaning interdental brush will be used.
by the patient. In the upper jaw,
Page - 99
7. DISINFECTION OF THE
COMPLETED WORK
The dental laboratories and the cleaned, infection and complications
dentists should agree on the are effectively prevented. This has a
disinfection practices. The seating of direct effect on the patient’s health
implants is always a surgical procedure. and his adaptation to wearing the new
When the prosthesis is carefully prosthesis.
Page - 100
PA R T III
CLINICAL
Implant prostheses
1. INTRODUCTION ...................................................105
PATIENT ..............................................................106
2.2 Tartar............................................................106
2.3 Gingivitis........................................................106
PATIENT ..............................................................108
PART I
PART II
PART III
1. INTRODUCTION
1. INTRODUCTION
2. ORAL HEALTH OF AN
IMPLANT PROSTHESIS
Tr aditional dentures are o f ten provide more information for dental PATIENT
considered cumbersome and hygienists, since they need to know
3. ORAL HYGIENE OF AN
unpleasant; some people never get how to clean an implanted mouth for
IMPLANT PROSTHESIS
used to them. Users do not feel the elderly or infirm who cannot do PATIENT
comfortable as they always have to so themselves.
PART IV
think about how to keep the denture
in place. Everyday functions such as This guide to oral hygiene contains PART V
eating, laughing and speaking may information on the health and care
cause a feeling of insecurit y. The of an implanted mouth, and will
poor stability of dentures may also help to explain the impor tance of
cause aching pressure wounds i.e. oral hygiene to successful implant
sore spots on the mucosa. Implant treatment. The guide deals with the
treatments offer a solution for cleaning of fixed prostheses as well
many of the problems involved in as prostheses fitted with a bar. The
dentures, so the popularity of implant guide will describe the oral cleaning
treatment will continue to increase. methods, gingivitis, the effect of oral
Special attention should be paid to health on general health, and the
the promotion of oral health and importance of regular follow-up and
the prevention of oral diseases in maintenance treatment. The guide
this growing group of patients, as in may be used when introducing the
many cases an implanted mouth will concept o f implant tr eatment to
require the adoption of new cleaning potential patients, or those who have
methods. Therefore, patient guidance already had it. It can also be used in
will become essential to enable the health-care training and in nursing to
patients to organise their daily oral provide more information for nursing
hygiene satisfactorily. Insuf ficient personnel, and in planning health
oral hygiene may, at worst, cause the education programmes.
loss of an implant. We also need to
1.10.2000
Jaana Turunen
Page - 105
2. ORAL HEALTH OF AN
IMPLANT PROSTHESIS PATIENT
Good oral hygiene is essential for bacterial, viral or fungal infections.
the success of an implant treatment. As well as making the mouth feel
Insufficient oral care may, at worst, clean and healthy, oral health also
cause the loss of an implant. When contributes to general health. Oral
cleaning the mouth, it is essential infections open a route for bacteria
to remove the plaque, as it causes to enter the body, causing illnesses
a similar infectious reaction around that are localised in other parts of the
an implant as it would around a body. It may also cause an existing
natural tooth. A healthy mouth feels general illness to become worse.
fresh and pleasant. There is no pain,
2.1 Plaque
Plaque is a light, paste-like coating of plaque at the marginal gingiva
made up of the bacteria naturally around the metal parts protruding
occurring in the mouth. The from the mucosa will cause gingivitis.
consumption of sugar-containing This is why plaque must be removed
products causes an increase in the every day.
amount of plaque. The accumulation
2.2 Tartar
Tartar is formed by bacterial plaque and cannot be brushed away. The
which, due to the minerals present uneven and coarse tar tar of fers a
in saliva, has calcified into a coarse good home for bacteria and plaque.
substance. Tartar sticks to the surface Together, they maintain gingivitis.
of both metal parts and prostheses
2.3 Gingivitis
Gingivitis may arise in 2-10 days when worse if the plaque is not removed
bacterial plaque is concentrated on and the infec tion not treated. As
the margin of the gingiva. Its creation the infection grows deeper into
is affected by the system’s ability to the tissue, the composition of the
resist bacterial intrusion in the gingival bacteria around the implant and in
tissue. With insufficient cleaning, the the periodontal pocket changes, and
plaque remains on the margin of the starts to destroy the tissues that hold
gingiva, working and irritating around the implant. As the bone around the
the metal par ts. When the plaque implant begins to disappear, it will
thickens and ages, it causes infection allow movement and eventually the
of the gingiva. The gingivitis may get loosening of the implant.
Page
Page- -106
106
Symptoms of gingivitis: YOU ARE IN:
• gingiva bleed easily when brushing • the colour of the gingiva changes
PART I
or eating hard food from salmon pink to dark red
PART II
• gingiva are sore and swollen • bad taste and/or smell in the
PART III
mouth.
1. INTRODUCTION
Page - 107
3. ORAL HYGIENE OF AN
IMPLANT PROSTHESIS PATIENT
The oral hygiene programme Oral cleaning must be done carefully
includes: and frequently, twice a day would
be ideal. Special attention must be
1. Cleaning the metal parts/bar and paid to cleaning the surfaces close to
the space between the prosthesis the tongue as they are more difficult
and the gingiva to clean. There is an ample range of
cleaning instruments on the market,
2. Cleaning the prostheses
so everyone should be able to find
something suitable. A rule of thumb is
3. Cleaning the mucosa and surveying
to have one brush for open surfaces
their condition
and another for enclosed spaces. The
Page
Page- -108
108
YOU ARE IN:
PART I
PART II
PART III
1. INTRODUCTION
2. ORAL HEALTH OF AN
IMPLANT PROSTHESIS
PATIENT
3. ORAL HYGIENE OF AN
IMPLANT PROSTHESIS
PATIENT
PART IV
PART V
Page - 109
3.2 Cleaning the implant-fixed bar
An interdental brush or
special dental floss may
be used for cleaning the
spaces in the bar. In addition
to brushing, toothpaste or
prosthesis paste may be
used in cleaning. Polishing
toothpastes should not be
used.
Page
Page- -110
110
3.3 Cleaning a fixed implant prosthesis YOU ARE IN:
PART I
PART II
PART III
1. INTRODUCTION
2. ORAL HEALTH OF AN
IMPLANT PROSTHESIS
PATIENT
3. ORAL HYGIENE OF AN
IMPLANT PROSTHESIS
PATIENT
PART IV
PART V
A floss threader may be used to pull the special dental floss under a
fixed prosthesis. In addition to brushing, prosthesis paste may be used
for cleaning a fixed prosthesis. Ordinary toothpaste would scratch the
acrylic surface of the prosthesis.
Page
Page- -112
112
3.4 Cleaning a removable prosthesis YOU ARE IN:
Cleaning the prosthesis is as important Effervescent tablets may also be used PART I
as cleaning natural teeth, as tartar, for removing discolouration.
PART II
plaque and an invisible film of bacteria
build up on the surface of the The prostheses are washed with PART III
prosthesis in the same way as they lukewarm water, as very hot water
1. INTRODUCTION
do on natural teeth. Clean prostheses may damage them. Special attention
should be paid to the surfaces that 2. ORAL HEALTH OF AN
feel and look better in the mouth, IMPLANT PROSTHESIS
and the whole mouth feels fresher. are in contact with the mucosa. PATIENT
Insuf ficiently cleaned pros theses The mucosa are cleaned with a soft
3. ORAL HYGIENE OF AN
may cause various bacterial, viral and toothbrush before the prosthesis
IMPLANT PROSTHESIS
fungal infections in the oral cavity. is replaced. Clean pros theses are PATIENT
A dental prosthesis must be cleaned replaced into a clean mouth.
3.1 Suitable cleaning
carefully at leas t t wice a day and instruments
When the prostheses are not in the
rinsed after every meal.
mouth, they have to be kept moist 3.2 Cleaning the implant-
fixed bar
There are special brushes for cleaning e.g. in a glass of water or wrapped
loose prostheses, with a wide head in damp paper in a watertight box. 3.3 Cleaning a fixed
If allowed to dry out, the prosthesis implant prosthesis
for cleaning large areas and a narrow
head to enter small holes. A so f t may twist and become unusable. 3.4 Cleaning a removable
brush is used to clean the mucosa. prosthesis
If the prosthesis rubs or feels
Prosthesis paste, washing-up liquid 3.5 Cleaning oral mucosa
uncomfortable, the dentist should be
or mild soap may be used for and surveying their
contacted. Likewise, if the prosthesis condition
cleaning. Prostheses must not be
suffers damage, if a prosthetic part or
cleaned with ordinary toothpaste as 3.6 Intensive oral cleaning
a screw has loosened or if the contact
it would scratch their acrylic surface.
pieces, i.e. the bar’s riders, have been 3.7 Follow-up and
maintenance calls
damaged, the dentist should, once
again, be consulted. PART IV
PART V
Page - 113
3.5 Cleaning oral mucosa and surveying their condition
It is beneficial to rinse the mouth of fers the per fect oppor tunity to
several times a day. In addition inspect the condition of the mucosa.
to cleaning, the brushing of the If you feel or notice something
tongue, the gingiva and the palate unusual in the mouth, e.g. changes in
improves circulation and keeps the the mucosa, coating, flushed areas,
tissue healthy. The prosthesis will hold pain, swelling, bad smell or taste etc.
bet ter in a clean mouth. Cleaning you should contact your dentist.
Page
Page- -114
114
CONTENTS:
1. INTRODUCTION ....................................................121
3. BENZODIAZEPINES
3.1. Operating mechanism ....................................124
3.2. Half-life .........................................................124
3.3. Pharmacodynamics ........................................125
3.4. Pharmacokinetic anomalies .............................125
7. COMPLICATIONS ..................................................140
7.1. Local complications........................................140
7.2 Hypoxia ..........................................................140
7.3. Fainting ........................................................140
7.4. Psychogenic complications .............................141
7.5. Other complications.......................................141
7.6. Legal aspects................................................142
7.7. Conclusions...................................................143
7.8. Instructions to patients .................................144
Page - 120
1. INTRODUCTION YOU ARE IN:
OSFIX implant treatment involves major from the procedure can then take PART I
operations. Thus the patients several hours, which will paralyse the PART II
frequently require sedation. To reach operations of the dental surgery for
PART III
an adequate and accurate effect, those hours.
these drugs have to be administered to PART IV
the vein. This is known as intravenous Although the basic doses for 1. INTRODUCTION
sedation (sedative medication intravenous sedation are 10 mg of
2. THE PATIENT FOR
introduced through the vein). It is diazepam and 5 mg of midazolam (note
SEDATION
not general anaesthesia. However, the difference in the efficiency ratio
even intravenous sedation involves of midazolam), the individual amount 3. BENZODIAZEPINES
risks which must be recognised, and for the patient is titrated to the exact 4. THE COMMERCIAL
due precautions for treating possible point through intravenous dosage. DRUGS
complications must be made. Hence oversedation or undersedation
5. MONITORING THE
will be extremely rare. There will be no PATIENT
Why should we use intravenous problems with the procedures and the
6. INTRAVENOUS
sedation, facing its intrinsic risks, rather patient’s recovery is swift. SEDATION IN PRACTICE
than oral sedation?
7. COMPLICATIONS
For the patient, intravenous sedation
This is a question which fellow dentists is a necessary alternative in dental PART V
frequently ask the author of this study. care. It should nevertheless not involve
To answer it we need to look at some risks which outweigh the advantages.
principles: orally, a useful dosage of The dentist and the dental surgery
diazepam is 10 mg for young and assistant must ensure that they have
adults, 5 mg for children. Smaller doses sufficient training for and a good
will not produce a useful sedation. The command of this procedure. These
dosages per os for midazolam are 7.5 skills must also be regularly rehearsed
to 15 mg. and developed. This is the only way to
avoid emergencies and complaints.
Given orally, in the majority of patients
these doses create good sedation, The purpose of these instructions
sufficient for a normal procedure. The is to provide a theoretical basis for
problem is that a minority of patients the understanding of intravenous
will not experience any sedative effect sedation, but the practical application
with these doses. In the case of a of the procedure necessitates manual
nervous patient, their experience of training and a demonstrated command
the treatment will be most unpleasant. of the subject.
Another minority of patients will
become oversedated with these doses,
to the point that they are practically
in a very deep anaesthesia during
the whole procedure, which severely
impairs the dentist’s work. Recovery
Page - 121
2. THE PATIENT FOR SEDATION
2.1 Examining the patient
Page - 122
at times, be the only possibility when The complications of an intra-arterial YOU ARE IN:
the patient’s clothing prevents the use injection are very severe; in the worst
of the cubical fossa or when no visible case they may lead to the loss of PART I
vein is found in the cubical fossa. the entire limb or a serious circulation
PART II
disorder therein. Therefore, patients
Use of the cubical fossa does present sedated intravenously must always be PART III
Page - 123
3. BENZODIAZEPINES
3.1 Operating mechanism
3.2 Half-life
Half-life means the time taken for the dosed straight into the vein. The
plasma concentration to decrease by absorption phase of oral drugs is
50%. It is important to note that this long and it depends on the uptake
is not the time the drug takes to of the drug.
disappear from the body, nor is it the 2) The distribution phase, during
time when the drug’s effect can be which the drug is distributed into
seen in the body. The terms ‘long half- tissue components according to its
life, ‘short half-life may sometimes properties, e.g. the liquid system
be confused with ‘long-acting’ and or fatty tissues.
‘short-acting’, therefore the meaning
3) The elimination phase which
of each should be kept clearly in mind.
begins when a balance between
For instance the half-life of diazepam
plasma and the other tissues
is several dozens of hours (24-48),
of the body has been reached.
whereas its active sedation time is only
Subsequently, the drug is
a few dozen minutes.
eliminated through liver
metabolism or kidney secretion
The following steps shall be observed
according to the drug’s half-life.
when dosing intravenous drugs:
The patient’s clinical recovery will
Page - 124
3.3 Pharmacodynamics YOU ARE IN:
All diazepines have the following four The action of benzodiazepines is based PART I
characteristics: on the stasis of benzodiazepine PART II
receptors. These receptors are found
1) Hypnotic or sleep inducing PART III
in the central nervous system. The
2) Anxiolytic (sedative, eliminating receptors are very specific to the PART IV
anxiety, calming) agonists and antagonists of
1. INTRODUCTION
3) Muscle relaxant effect benzodiazepine. They are not receptive
to other sedative agents such as 2. THE PATIENT FOR
4) Prevention and reduction of
SEDATION
convulsions. barbiturates.
3. BENZODIAZEPINES
3.2 Half-life
In overdose cases where the patient plasma level is already decreasing
has taken massive amounts of (compare with getting drunk and 3.3 Pharmacodynamics
diazepam (as much as 400 times sobering up). 3.4 Pharmacokinetic
the usual dose), plasma levels are anomalies
extremely high for several days. The The lack of correlation between
4. THE COMMERCIAL
patient will, however, recover clinically drowsiness and drug plasma levels DRUGS
to the extent that he is fully alert and is also evident when the patient is
5. MONITORING THE
able to leave the hospital considerably prescribed diazepam for continued PATIENT
sooner than the elimination time of use. The patients tend to be tired
the drug.
6. INTRAVENOUS
during the first few days, even though
SEDATION IN PRACTICE
the plasma level is still rising over
It is important to understand that the the following days. The steady state 7. COMPLICATIONS
clinical maximum effect of a drug does level, in which the elimination and PART V
not have a correlation with its plasma further administration are in balance,
level. This is quite apparent when a is reached much later. The effect of
drug is administered intravenously: a given dose depends more on the
while the drug’s plasma level is still speed of increase of the plasma level
increasing, the patient is much more than the plasma level itself.
sedated and tired than when the
Page - 125
4. THE COMMERCIAL DRUGS
4.1 Selecting a suitable drug
4.2 Diazepam
Page - 127
4.3 Midazolam
Page - 128
erythromycin. All these drugs elderly people and weak patients, YOU ARE IN:
contribute to a longer active period or and to patients suffering from an
a stronger response. It must especially obstructive pulmonary disease, chronic PART I
be noted that midazolam should be kidney deficiency or cardiac
PART II
administered with special caution to insufficiency.
PART III
1. INTRODUCTION
Disposable syringe: for premedication Infusion liquid: A physiological sodium
with midazolam, the most practical chloride liquid (0.9%), available at 2. THE PATIENT FOR
SEDATION
size is 5 ml, and for diazepam, 2 ml. the pharmacy, is used in intravenous
sedation. It comes in both glass and 3. BENZODIAZEPINES
Needle: needles are needed for the
4. THE COMMERCIAL
transfer of the drug from the ampoules DRUGS
to the syringe. Ideal needles are as
4.1 Selecting a suitable
wide and long as possible, e.g. ones drug
with a Luer connector.
4.2 Diazepam
Page - 129
plastic containers. A volume of half Pharmacies have a wide range of
a litre is quite sufficient for sedation various surgical tape materials packed
purposes. The rate of the infusion in rolls, so finding a suitable one for
should be fast at the beginning of attaching the cannula should cause no
sedation, and when the sedation level problems.
is sufficient, the rate of the infusion
may be set to one drop per 2-3 Venous stasis: A venous stasis is
seconds (=1 ml/min). attached above the cannulation site
to raise the veins. It should direct the
Surgical tape: The cannula is attached pressure to prevent the return of the
so as to permit no movement. A blood through the veins but to allow
strong adhesive tape, preferably in a the blood pressure to fill the limb.
y-form bandage, should be employed.
Additional oxygen is the most frequent The resuscitation drugs listed in the
supplement required in intravenous general dental studies should be
sedation. An oxygen cylinder is an available at the surgery. These are 1)
absolute necessity and no procedures epinephrine, 2) diazepam, 3) atropine,
should be started if there is not 4) cortisone, and various liquids to
enough oxygen for several hours’ solve the above, as well as the syringes
administration. Nasal cannula are ideal and needles to administer them. In
for administering oxygen during the addition to these, intravenous sedation
procedure as an oxygen mask cannot procedures require certain drugs
be used. primarily intended to cure respiratory
depression and to support the
Precautions against respiratory arrest cardiovascular system. These drugs
shall be made with a emergency are:
resuscitator, “Ambu”, that is connected
• nalorphin (Nalorfin®), which cures
to the oxygen. During the procedure
the respiratory depression caused
the sedationist must have both the
by opiates;
possibility and the ability to perform
an endothracheal intubation for the • flumazenil (Lanexat®) to impede
patient if needed. This makes the benzodiazepine receptors and
intravenous sedation a suitable next thus cure the respiratory
step after becoming experienced with depression caused by
nitrous oxide. The above mentioned benzodiazepines. Flumazenil is a
resuscitation methods must be learnt benzodiazepine antagonist and it is
before a permit to use nitrous oxide available in 5 ml ampoules. They
will be granted. contain 0.5 mg of the drug or 0.1
mg/ml. It is important to always
have the antagonist within reach
in case any problems should arise
during the procedures.
Page - 130
• doxazepram; (Dopram®), which All the above mentioned drugs are in YOU ARE IN:
stimulates the respiratory centre in injection form and require the correct
the brain; training in addition to learning their PART I
• salbutamol (Ventoline®) opens the properties from the available literature.
PART II
pulmonary tubes e.g. in connection It is of the utmost importance that
all necessary emergency/resuscitation PART III
with status asthmaticus;
drugs are within reach of the dental PART IV
• etilephrine (Effortil®) which is used
surgeon performing the operation,
to increase the volume per minute 1. INTRODUCTION
and that the expiry dates of ampoules
of the heart and to increase blood
are duly followed. Moreover, the 2. THE PATIENT FOR
pressure. SEDATION
ampoules should not be opened until
immediately before use as an opened 3. BENZODIAZEPINES
ampoule will not keep.
4. THE COMMERCIAL
DRUGS
4.2 Diazepam
4.3 Midazolam
4.4 Administration
equipment
5. MONITORING THE
PATIENT
6. INTRAVENOUS
SEDATION IN PRACTICE
7. COMPLICATIONS
PART V
Page - 131
5.MONITORING THE PATIENT
The safety and well-being of the
patient are the responsibility of the
operating dental surgeon. All sedated
patients must be monitored. The
cost of monitoring equipment is no
excuse for not monitoring the patient.
Monitoring results should be carefully
recorded. The most important
monitors of all are the eyes and ears of
the person carrying out the procedure,
which means that the patient must
be observed closely during the whole
procedure. This is the way to avoid
unnecessary problems. If the data
gained through electronic monitoring
is in contradiction with clinical
observations, human intelligence and
observation skills are needed to solve
the situation. Even though monitoring
is essential, it will never replace the
human senses, only enhance them.
Page - 132
5.2 Pulse oximetry YOU ARE IN:
The functions of the body depend on in which the monitoring occurs PART I
a continuous intake of oxygen. This continually through the skin. The
PART II
vital supply has been secured by oximeter is usually connected to a
many means, the most important of finger, but other monitoring sites such PART III
which is the ability of haemoglobin to as the earlobe are also suitable. PART IV
bind oxygen. The amount of oxygen
1. INTRODUCTION
bound in haemoglobin depends on Pulse oximetry was developed for
the prevailing oxygen pressure, but clinical use in the mid-1970s in Japan. 2. THE PATIENT FOR
SEDATION
an essential fact is that the During the 1980s, this monitoring
dependence is not linear but creates a system became extremely popular 3. BENZODIAZEPINES
co-ordination curve forming a gentle and, during the last few years, it
4. THE COMMERCIAL
S. The amount of oxyhaemoglobin, has, in many countries, even been DRUGS
oxygenated haemoglobin, in the total considered compulsory in the control
5. MONITORING THE
amount of haemoglobin, is called of general anaesthesia. Since 1986,
PATIENT
oxygen saturation, measured as a pulse oximetry has become so popular
percentage. The flat end of the oxygen worldwide that it is considered by many 5.1 Blood pressure monitors
dissociation curve of haemoglobin to be the most important monitoring 5.2 Pulse oximetry
ensures good oxygen saturation across system in anaesthesia.
6. INTRAVENOUS
a wide variation of oxygen pressure. SEDATION IN PRACTICE
On the other hand, the steep fall of Pulse wave oximetry also utilises the
7. COMPLICATIONS
the curve enables the quick delivery information contained in the pulse
of oxygen to the areas with oxygen wave. Even though it used only to PART V
pressure characteristic of certain function in the monitoring of the
tissues. timing of the saturation, the pulse wave
printed on the screen is becoming a
Oximetry measures oxygen saturation, regular feature of the equipment. The
or the percentage of oxyhaemoglobin. size of the pulse wave is subject to
It can also be measured in a laboratory great variation according to various
test from an arterial blood sample, factors and thus it reflects the changes
but nowadays oximetry normally refers in blood flow at the monitoring site.
to a non-invasive monitoring system
Page - 133
commonly believed. Saturation may intravenous analgesics or sedatives.
decrease in cases where anaesthesia The situation is usually relieved with
has to be complemented with the application of oxygen.
There are certain sources of default oxygen pressure. Therefore, the shape
within pulse oximetry and pulse wave of the dissociation curve should always
oximetry, although as such they are be considered when interpreting the
quite reliable methods. oxygen saturation values.
The absorption of red light is not In pulse oximetry, the saturation and
specific to oxyhaemoglobin, as the pulse rate values require a pulsating
same phenomenon is created by circulation, but the values remain
the bonding of carbon monoxide to reliable even during poor peripheral
haemoglobin. This is visible, e.g., in a circulation.
patient who is a heavy smoker.
Page - 134
6. INTRAVENOUS SEDATION IN YOU ARE IN:
PRACTICE PART I
1. INTRODUCTION
6.1 Cannulating the vein in the crook of the arm
2. THE PATIENT FOR
SEDATION
Before the patient arrives, the for cannulation purposes as it is
3. BENZODIAZEPINES
following equipment should be individually packed and can be
prepared: attached by the patient or his parent 4. THE COMMERCIAL
DRUGS
in an agreed place. The anaesthetic
• a 5 ml syringe
effect begins after 1 hour and thus 5. MONITORING THE
• a large needle (G 21) for the suction to be useful the product should be PATIENT
of the drug supplied in advance, for the patient 5.1 Blood pressure monitors
• intravenous cannula to apply at home. More detailed
5.2 Pulse oximetry
• alcohol swab information on the product can be
found in the national Pharmaca. 6. INTRAVENOUS
• drugs
SEDATION IN PRACTICE
• venous stasis
A venous stasis is placed on the 6.1 Cannulating the vein in
• infusion fluid package patient’s arm to provide good visibility the crook of the arm
• infusion tube of the veins. When fitting the venous 6.2 Administering the drug
stasis, it should be remembered that and observing the
The patient’s weight should be effects
the pressure should not be so great
determined beforehand or, if it has
that arterial circulation in the arm is 6.3 Recovery from sedation
not been, it should be verified at
obstructed. Following this, the cannula
this point. The drug is nevertheless 7. COMPLICATIONS
is attached and fixed to the skin with
dosed primarily according to individual
adhesive tape. PART V
reactions and only secondarily in
accordance with the patient’s weight.
The salt solution is placed in the
infusion stand and the chamber of
The patient is placed into an almost
the intravenous line is filled with the
supine position, his blood pressure is
liquid. The whole length of the tube
taken and the probe for the pulse
is checked carefully for air bubbles.
oximeter is attached, then the initial
The infusion tube is attached to the
values for blood pressure and oxygen
cannula and for a while the infusion
saturation are recorded.
valve is set to allow maximum flow. This
is to ensure that the flow is free and
The cannulation can also be carried
the surrounding tissue is not swelling
out completely without pain with an
as a sign of paravenous infusion. At this
emulsion ointment or plaster (Emla ®)
point it will be evident if the injection
to numb the skin for the cannulation
has punctured an artery, as blood will
procedure. The plaster is more practical Page - 135
rush up the injection tube.
6.2 Administering the drug and observing the effects
When the infusion is working normally, further doses should be given if the
the administration of midazolam pulse oximeter value is equal to or
begins. With a disposable syringe, lower than 95%.
midazolam (1 mg/1 ml) is given in
1 mg doses. The doses are repeated If sedation is to be followed by
every 2 minutes. A conversation is a surgical procedure, it is worth
held with the patient throughout the reminding the patient that he may
administration, on any subject, to sleep while the team is preparing the
observe the impairment of the motor operating room ready for surgery. The
co-ordination of speech. Other motor patient will usually fall asleep a few
disorders can be observed e.g. by minutes after the conversation with
asking the patient to touch his nose him has stopped.
before every new dose of drugs. The
point at which the patient closes his Before surgical procedures it is always
eyes is also noted, and pulse oximeter good to give the patient a small
values are observed. An appropriate dose of fentanyl (50 microgram/ml)
level of sedation is reached when immediately before the surgery, e.g.
one of the following observations is 25 micrograms of fentanyl is usually
made: sufficient. The advantage of this is
that the patient reacts less to small
• the patient’s speech becomes
sensations of pain which may arise
slurred
despite sedation. As fentanyl is also a
• the patient closes his eyes or seems powerful respiratory depressant, the
to be somnolent value displayed by the pulse oximeter
• the value in the pulse oximeter must be checked before administering
decreases by 2-3% of the initial the drug. In conventional treatment
value as a result of decreased (e.g. extraction, root treatments etc.)
respiration rate. the treatment should be initiated
immediately after the sedation
Sedation is commenced, and especially
becomes effective. An additional 1 mg
for anxious patients, local anaesthetics
of midazolam (see the pulse oximeter)
containing epinephrine should be
is recommended, where after the
avoided as a possible tachycardia
saliva aspirator is placed on site. A
reaction caused by epinephrine may
recommended suction fan is the short
disturb a good sedation. Calmness
loop-form aspirator. These aspirators
should always be maintained when
work like a string, thus helping the
handling the patient as he is awake
patient to keep his mouth open.
and by no means anaesthetised.
Oxygen saturation is monitored closely, will repair, almost without exception, PART II
both during the procedure and during the onset of hypoxia. If the respiratory PART III
the recovery from sedation. If oxygen depression is caused by
PART IV
saturation falls below 90%, it is benzodiazepines and the low oxygen
important to immediately check the saturation is not increased by oxygen 1. INTRODUCTION
patient’s respiration movements and administration, the patient should
2. THE PATIENT FOR
openness of airways. It is also be intravenously administered some SEDATION
diagnostic to know if the decrease is flumazenil (Lanexat 0.1 mg/ml à 5 ml).
3. BENZODIAZEPINES
sudden or slow. In some cases, the This drug can be dosed in 0.1 mg
reason may be local to the point of i.e. 1 ml portions which are repeated 4. THE COMMERCIAL
DRUGS
measurement: it should be checked every minute until the oxygenation
that the probe does not apply so much has returned to normal. The dosage 5. MONITORING THE
pressure to the monitoring site that it may rise to a maximum of 1 mg (10 PATIENT
obstructs circulation. In such an event, ml). 6. INTRAVENOUS
the probe should be moved to another SEDATION IN PRACTICE
finger, but only after the exclusion of If respiration depression is caused 6.1 Cannulating the vein in
genuine oxygen desaturation. Should by benzodiazepines, return to normal the crook of the arm
you suspect a malfunction of the oxygenation is very fast and will occur
6.2 Administering the drug
probe, use your own finger to test the during the very first doses. and observing the
function of the probe. effects
As flumazenil is a benzodiazepine
6.3 Recovery from sedation
If the value remains unchanged, antagonist, it blocks the same
airways are open and the patient is receptors as those to which 7. COMPLICATIONS
breathing, additional oxygen should benzodiazepines are attached. PART V
immediately be given to the patient. Therefore flumazenil may be given in
A nasal cannula and a regular 3-10 l a sufficiently small amount to prevent
oxygen cylinder (e.g. AGA) are suitable, an eventual respiration depression, but
providing that there is enough oxygen not to lose the sedation. The procedure
for several hours’ use. The may then continue normally.
administration of additional oxygen
Page - 137
6.3.2 Flumazenil
Page - 138
YOU ARE IN:
eliminate the sedation can sit and After the procedure, the patient may PART I
stand normally. It must, however, be be sent home 3 hours after the last PART II
remembered that they remain sedated dose of midazolam. He should be
and cannot fully look after themselves. provided with an adult escort. Both
PART III
It is crucial to remember that the the patient and his escort should be PART IV
effective time of flumazenil is shorter reminded of the written instructions
1. INTRODUCTION
than that of midazolam and, in theory, which the patient received on his
the sedation with eventual respiratory previous visit; the main points being 2. THE PATIENT FOR
SEDATION
depressions may return, even though that the patient’s ability to observe
the long duration of dental procedures traffic is impaired in the 12 hours 3. BENZODIAZEPINES
makes it highly unlikely. The presence to follow, and that he should not
4. THE COMMERCIAL
of an escort is, even in these cases, consume alcohol during this time, as it DRUGS
absolutely necessary. The escort gives would increase the effect of the drugs
5. MONITORING THE
the patient a feeling of security and vice versa. Some people may show PATIENT
and someone to talk to about the unpredictable individual reactions. The
6. INTRAVENOUS
experience. patient should be made aware of the
SEDATION IN PRACTICE
dentist’s office and home telephone
numbers in case any help is needed 6.1 Cannulating the vein in
the crook of the arm
after the treatment.
6.2 Administering the drug
and observing the
effects
7. COMPLICATIONS
PART V
Page - 139
7. COMPLICATIONS
7.1 Local complications
7.2 Hypoxia
Page - 140
7.3 Fainting YOU ARE IN:
An extremely nervous patient may should be carried out during this PART I
produce a vasovagal collapse, either appointment. The patient is given PART II
before or during the administration of a new appointment and it should
PART III
the drug. In this case the procedure be considered whether part of the
should immediately be discontinued diazepam or midazolam should be PART IV
and normal instructions against given beforehand per os for instance
1. INTRODUCTION
fainting should be followed. First, the 1-2 hours before the appointment.
limbs are raised. No dental procedure 2. THE PATIENT FOR
SEDATION
4. THE COMMERCIAL
Patients who are under psychiatric recorded in which patients undergoing DRUGS
medication or treatment are not suited intravenous sedation have had sexually
5. MONITORING THE
to intravenous sedation. There are coloured illusions, the worst of which PATIENT
some descriptions of paradoxical have even led to prosecution of the
6. INTRAVENOUS
excitement which is mainly found in sedating physician. This is why it is very
SEDATION IN PRACTICE
children, but in individual cases there important that all monitoring is set up
before the sedation. This particularly
7. COMPLICATIONS
have been aggressive reactions even
with adults. The only way to deal applies to EKG monitoring; the patient 7.1 Local complications
with the situation seems to be to should not, whilst under sedation,
7.2 Hypoxia
discontinue the procedure. A more undergo procedures which he would
common reaction is a decrease in the not expect a dentist to perform. For 7.3 Fainting
patient’s conscious inhibition, so that security reasons, it is also vital that 7.4 Psychogenic
the patient becomes very talkative another member of staff is present complications
and says things he would not normally during the whole of the treatment
7.5 Other complications
mention. When initiating sedation, it is process: at the initiation of sedation,
during the procedure and during the 7.6 Legal aspects
good to lead the conversation towards
harmless topics, as the amnesia caused recovery period. A good precaution 7.7 Conclusions
by the drug may further distort the for the dentist’s legal protection is
7.8 Instructions to patients
recollection on the contents of the to make a video recording of the
conversation. Some cases have been procedure and to file the tapes. PART V
There is a small group of patients who, latter group may look the dentist in
after being given a few milligrams of the eye after a 10 mg dose and say,
diazepam or midazolam, will fall into “It doesn’t make any difference at all”.
deep sleep, as the dose does not What must be remembered, however,
depend on the patient’s weight. A is that the patient may be sedated
large patient may reach deep sedation despite his claims to the contrary. This
while a small patient who weighs very case would call for psychomotor tests
little may take a much larger dose. The such as asking the patient to touch his
Page - 141
nose. It is likely that he cannot perform • Always ask how the patient feels
this trick. Requesting a signature on both at the beginning of the
a piece of paper would easily reveal infusion and when giving the first
the depth of the sedation. Increasing drugs. Ask whether he can feel any
the dose for an extremely resistant local pain and if not, all is well.
patient may lead to a quick and deep
An intra-arterial infection may cause
drop into oversedation. Therefore, a
an ischemy and necrose of the distal
key rule is not to give the patient
part of the whole arm. In case of acute
more than 10 mg midazolam or 20 mg
respiratory or oral infection causing
diazepam intravenously.
the obstruction of airways, intravenous
sedation is contraindicated. Acute
The intravenous administration of
dental patients are ill-suited to
midazolam has few cardiovascular
intravenous sedation. Thus acute
effects. The problems i.e. intra-arterial
processes must first be brought under
injections are easily avoided when the
control through draining or antibiotics,
following is kept in mind:
only then can the procedure be
• Only use a vein that is clearly undertaken under local anaesthesia
visible, and only after placing the and intravenous sedation.
cannula should the infusion tube be
connected.
Page - 142
When these instructions are followed, experienced colleague. The patient YOU ARE IN:
everything is likely to go well. If should also be offered a meeting with
problems do arise with a patient, this more experienced colleague. If PART I
they can usually be solved in a quiet legal procedures must be taken, the
PART II
and informative discussion with the primary task is to contact the lawyer
patient. If not, it might be useful of the dentist or the dentists’ union. PART III
for the dentist to contact a more PART IV
1. INTRODUCTION
7.7 Conclusions
2. THE PATIENT FOR
has thorough knowledge of this SEDATION
Intravenous sedation is, both for the
dentist and his patient, a pleasant, anesthesiological method. The skill 3. BENZODIAZEPINES
efficient and safe means of treating should also be continuously
4. THE COMMERCIAL
anxiety problems. The basis for this maintained. Endothracheal intubation
DRUGS
security is, however, the appropriate exercises should not be practised only
once, but this life-saving procedure 5. MONITORING THE
skills of the staff. Therefore, in the PATIENT
conditions prevailing in the northern in a severe complication should be
practised annually at a central hospital. 6. INTRAVENOUS
European dental education tradition,
SEDATION IN PRACTICE
instructions could be given where the Neither should intravenous sedation
PART V
Page - 143
7.8 Instructions to patients
Page - 144
Page - 146
PART V CONTENTS:
OVERLOADING .............................................................181
COATING......................................................................193
SCIENTIFIC PUBLICATIONS
- 1998 1999
• Luotio*, Ryhänen, Petrelius, • Luotio*: Mandibular complete
Kotilainen: The Clinical Follow-up denture stabilization with dental
of The Osfix Dental Implant implants: 1st Baltic symposium on
System: pilot results after one osseointegrated implants. Riga,
year: Latvia 6.-7.10.1999.
Page - 148
YOU ARE IN:
PART I: Clinical
1.1 ABSTRACT
In this study, a total of 40 aluminium oxide sandblasted, custom made and
cast pure grade-2 titanium implants were inserted into the mandibular bones
of 10 beagle dogs. Characterisation of the implant surface was performed
by standard SEM-methods. X-ray measurements and histomorphometrics were
used to analyse the osteointegration properties. The surface of the titanium
after sandblasting shows extensive roughening and the surface consists of
70-80 % titanium and 20-30 % aluminium, both as oxides. The success rate of
immediate implantation was limited, but all of the implants, none of which were
more than 1mm above the bone margin, met the success criteria. Examination
by conventional microscopy proves that the majority (65 %) of the implant
surface is in contact with bone.
Page - 151
1.2 AIM OF STUDY
The purpose of this study was to titanium implants in beagle dogs. A
characterise the surface of pure further aim was to determine the
titanium which has been abraded depth at which dental implants should
or roughened with aluminium oxide be inserted in the mandible bone to
sandblasting and to chart the progress achieve optimal osteointegration.
of the osteointegration of sandblanted
OVERLOADING
1.4.1 Analysis of titanium material
COATING
The implants were analysed by light titanium material. However these
microscopy and scanning electron particles were rare. The x-ray emission
microscopy. The surface of titanium shows that the surface contains
after sand blasting shows extensive 70-80 % titanium and 20-30 %
roughening. aluminium, both oxides .
Page - 153
Page - 154
YOU ARE IN:
PART I: Clinical
PART II: Laboratory
PART III: Hygiene
AI Ti
PART IV: Sedation
PART V: Studies
ANIMAL STUDY
CLINICAL STUDY
FOLLOW-UP STUDY
1.4.2 Primary success rate
OVERLOADING
The success rate of immediate The majority of the unsuccessful
COATING
implantation was 67 %, only 19 implants implants (7) represented cases in which
from the original 27 were considered at least 2mm of the implant was above
successful (the depth of bone pocket the bone margin. On the other hand,
was less than 1mm.) and 8 implants all of the implants which were 1mm or
were unsuccessful (the depth of bone less above the bone margin met the
pocket was greater than 1mm). success criterion.
Bone pocket (mm)
Page - 155
1.4.3 Microscopic evaluation of osteointegration
Implant 14 100 % 0%
Page - 156
1.5 DISCUSSION YOU ARE IN:
PART I: Clinical
The success rate of this immediate treatment. Feighan et al. (1995)
implantation technique was only 67 %. concluded that the length of the bone- PART II: Laboratory
This result demonstrates the benefit implant interface for the implants that
of submerged implantation technique. had been sandblasted with aluminium
PART III: Hygiene
Fugazzotto (1993) and his co-workers oxide was significantly greater than for PART IV: Sedation
studied a large group of submerged plain polished implants. Sandblasting
implants in humans. Their absolute affected the area of bone formation PART V: Studies
success rate were 96.4 % and 98.4 % on the implant and the shear strength ANIMAL STUDY
in maxilla and mandible respectively. at the bone-implant interface.
CLINICAL STUDY
Cumulative success rates were, at the Wennerberg (et al. 1995) and Piattelli
end of study, 92.9 % and 95.8 %. These et al. (1998) also concluded strong FOLLOW-UP STUDY
implants were followed in function osteointegration of aluminium-oxide
OVERLOADING
for 6 to 60+ months. Babbush and sandblasted titanium implants.
Shimura (1993) also studied a total COATING
survival rate of rough surface implants. The primary success rate of immediate
The five-year survival rate of a total implants was low in this study, but the
of 1,059 implants was 95 %. More area of solid bone in direct contact
recently, De Leonardis et al. (1999) with the implant surface was equal
finalised the results of a five year to other studies: Titanium implant
study, in which they achieved a 98 % systems were apposed by more bone
success rate with 100 rough surface than ceramic systems. Between 41 %
implants in submerged implantation. and 50 % of the surface of integrated
However, Watzek et al. (1995) also ceramic implants were apposed by
found very promising results in bone, whereas between 50 % and
immediate implantation. After a mean 65% of the surfaces of titanium
follow up period of 27.1 months, 97.7 % implants were apposed by bone
of the implants were found to be according to the studies of Steflik et
functioning successfully. The results al. (1996). Similarly, Sennerby et al.
of their study indicate that immediate (1991) have found that in humans, a
implantation can be considered to be large proportion of the implant surface
a very promising implant treatment (56-85 %) appeared to be in direct
method, if specific parameters and contact with the mineralised bone.
surgical details including proper flap Trisi et al. (1999) also investigated
elevation and sufficient bone quality osteointegration of rough surface
and quantity are taken into account. titanium implants in human low-
density jawbone. Bone-implant
The surface of an implant roughened contact was between 59-77 % whereas
by aluminium-oxide sandblasting does the results for implants with a smooth
not prevent osteointegration, even surface was only 4-7 %. This study
though small quantities of aluminium showed that a rough implant surface
oxide can be detected on the surface may enhance the rate of
of implant following the sandblasting osteointegration, but it is not able to
Page - 157
significantly change the bone density. not standardised i.e. sagittal cutting
A problem arises when attempting to shows mainly spongious bone and
compare these results because the frontal cutting compact bone.
direction of cutting the specimens is
1.5.1 Conclusions
The pure titanium which was abraded experiences in the cases with
by aluminium oxide sandblasting shows insufficient bone quality in which
a rough surface containing minor - similarly - the optimal position
aluminium remnants. This surface of implant and marginal bone were
demonstrates normal osteointegration not reached. The clinical success in
properties in beagle dogs but only in implantation depends mainly on the
cases with optimal insertion depth. optimal position of the implant and
Our results are in harmony with clinical the quality of the bone.
1.5.2 Acknowledgements
The authors want to thank the the University of Turku for their help in
Professors R-P. Happonen and A. producing the histological preparates.
Yliurpo of the School of Dentistry at
Page - 158
REFERENCES Sennerby L, Ericson L, Thomsen P, YOU ARE IN:
Lekholm U, Astrand P : Structure
Babbush C, Shimura M : Five-year
of the bone-titanium interface in
PART I: Clinical
statistical and clinical observations
retrieved clinical oral implants. Clin PART II: Laboratory
with the IMZ two-stage
Oral Implants Res 1991 : 2 : 103-11.
osteointegrated implant system. Int PART III: Hygiene
J Oral Maxillofac Implants 1993 : 8 :
Steflik D, Lake F, Sisk A, Parr G,
245-53. PART IV: Sedation
Hanes P, Davis H, Adams B, Yavari J :
A comparative investigation in dogs: PART V: Studies
De Leonardis D, Garg A, Pecora G :
2-year morphometric results of the
Osseointegration of rough acid- ANIMAL STUDY
dental implant-bone interface. Int J
etched titanium implants: 5- year CLINICAL STUDY
Maxillofac Implants 1996 : 11 : 15-25.
follow-up of 100 minimatic-implants.
FOLLOW-UP STUDY
Int J Oral Maxillofac Implants 1999 :
Trisi P, Rao W, Rebaudi A : A
14 : 384-91. OVERLOADING
histometric comparison of smooth
and rough titanium implants in COATING
Feighan J, Goldberg V, Davy D, Parr
human low-density jawbone. Int J
J, Stevenson S : The influence of
Oral Maxillofac Implants 1999 : 14 :
surface-blasting on the incorporation
689-98.
of titanium-alloy implants in a rabbit
intramedullary model. J Bone Joint
Watzek G, Haider R, Mensdorff-Pouilly
Surg Am 1995 : 77 : 1380-95.
N, Haas R : Immediate and delayed
implantation for complete restoration
Fugazzotto P, Gulbransen H, Wheeler
of the jaw following extraction of all
S, Lindsay J : The use of IMZ
residual teeth: a retrospective study
osteointegrated implants in partially
comparing different types of serial
and completely edentulous patients:
immediate implantation. Int J Oral
success and failure rates of 2,023
Maxillofac Implants 1995 : 10 : 561-7.
implant cylinder up to 60+ months in
function. Int J Oral Maxillofac Implants
Wennerberg A, Albrektsson T,
1993 : 8 : 617-21.
Andersson B, Krol J : A
histomorphometric and removal
Piattelli A, Manzon L, Scarano A,
torque study of screw-shaped
Paolantonio M, Piattelli M : Histologic
titanium implants with three different
and histomorphometric analysis of
surface topographies. Clin Oral
the bone response to machined and
Implants Res 1995 : 6 : 24-30.
sandblasted titanium implants: an
experimental study in rabbits. Int J
Oral Maxillofac Implants 1998 : 13 :
805-10.
Page - 159
Page - 160
YOU ARE IN:
PART I: Clinical
PART II: Laboratory
PART III: Hygiene
PART IV: Sedation
PART V: Studies
The OSFIX Dental Implant System ANIMAL STUDY
- A Three-year Follow-up Study
CLINICAL STUDY
FOLLOW-UP STUDY
OVERLOADING
Luotio K., DDS, PhD1,2 , Ryhänen J., DDS 1 , Kotilainen R., DDS, PhD, Prof.1,
COATING
Petrelius U., DDS1, Hanhela M., MSc 2
2.1 Abstract
Osfix implants are pure grade 2 titanium implants, the surfaces of which have
been mechanically roughened by sand blasting with aluminium oxide. The
integration property of the surface processing has been previously studied with
animal tests and histology. The aim of the Osfix clinical study was to verify
the success rate of the Osfix system. A total of 59 patients were operated on
and the number of implants inserted was 210. After a 3 month healing period,
impressions for the bar structures were taken and the mesiostructure bars
fabricated. These bars were then connected to an over-denture.
The follow-up results are available for 57 patients (203 implants). At the time of
the secondary operation, all of the implants were stabile. At the 3 year follow-up
inspection, no implants were lost. The success rate was 100 % for the implants
followed for 3 years. Patients were radiographically evaluated annually and the
mean marginal bone loss was 0.59mm (SD 0.42) after 1 year, 0.47mm (SD 0.42)
after 2 years and 0.58mm (SD 0.50) after 3 years. After the first year’s initial
marginal bone loss, no increase in bony pocket depth was detected. No clear
relationship between age, gender or number of implants inserted was noted.
Page - 161
2.1.1 Aim of the Clinical Study
The purpose of this clinical study was system and to observe the events
to verify the success rate of the Osfix causing possible de-integration.
The Osfix implant is a cylindrical implant 2 pure titanium and the implant
with an apical thread for increased surface is mechanically coarsened by
primary stability. The implant has an sand blasting with aluminium oxide.
internal hexagon for tightening during The length of the study implant
surgery. The implant is made of grade was 13.5mm and the outer diameter
3.75mm.
2.2.2 Patients
Gender M 23 40%
F 34 60%
No. of 3 25 44%
implants 4 32 56%
per patient
Page - 162
2.2.3 Surgery YOU ARE IN:
PART I: Clinical
The implant site was exposed by a The implants that would come into
large mucoperiosteal flap. A horizontal contact with the bone were removed PART II: Laboratory
incision was made on the crest of from sterile ampoules and inserted
the ridge, extending distally to the directly into the implant site to avoid PART III: Hygiene
mental foramens. A vertical releasing contamination with foreign material.
PART IV: Sedation
incision in the median line was Four implants were used in the cases
sometimes required to achieve better of no or moderate resorption and PART V: Studies
visibility of the field of surgery. The three implants in the cases of severe
ANIMAL STUDY
mucoperiosteal flap was then raised resorption of the jaw bone (figures on
and the position of the mental next page). The implants were initially CLINICAL STUDY
foramens identified and accessory tapped into the holes with a mallet FOLLOW-UP STUDY
local anaesthetics injected into them. and thereafter screwed and tightened
OVERLOADING
Palpation of the undercuts with the aid with a ratchet. The upper edge of
of a periodontal probe or elevator was the implant was placed 0.5-1.0mm COATING
performed in order to avoid critical below the upper bone margin. Before
areas in the lingual area during surgery. wound closure, a primary cover screw
The alveolar crest was smoothed with was screwed onto the implant. The
a large round drill and the implant cover screw, which is 1.5mm in height,
sites marked with a small round drill. remains 0.5-1.0mm above the level
The implant bed was prepared with a of the bone. An antibiotic steroid
standard drilling set cooled by external ointment (Terra-Cortril-P, Pfizer,
irrigation with cold saline to a diameter Brussels, Belgium) was applied to
of 3.7mm and depth of 15mm. The the cover screw. Finally, the wound
Osfix system allows free angulation, was sutured with interrupted and
but requires 5-15 degrees angulation continuing sutures.
between holes.
After primary surgery, a healing period Impressions for the bar retention
of 3 months is required before second structure were taken at this secondary
stage surgery. During this period, new operation. The positions of the cover
dentures for both the upper and lower screws were identified with a probe
jaws were fabricated. Impressions were and exposed with a scalpel. The
taken with a facebow and the dentures cover screws were unscrewed and
constructed according to the principle the impression posts inserted. The
that the canines should be parallel impression was taken with a newly
with a line between the condyles of fabricated lower jaw denture, which
the jawbone. had been relieved to make space
for the impression material. The
impression material was a vinyl
polyxane (Express, 3 M Dental
Page - 163
Products, St. Paul, MN, USA). Finally, prosthetic screws. The space between
the impression posts were unscrewed the prosthetic screws and the bar
and the wound re-closed with catgut retention were sealed with an antibiotic
sutures. The cover screws were then steroid ointment (Terra-Cortril-P,
reinserted until the next appointment. Pfizer, Brussels, Belgium). The
The impression posts were placed in prosthetic screws were retightened
the impression, which was sent to the after one week, because the structure
Osfix laboratory for production of the and design of the Osfix system is so
mesiostructure. accurate that friction between the
components may prevent complete
In the dental laboratory, the Osfix tightening at the initial fitting. Once
Bar was produced using prefabricated the screws had been retightened,
burn-out components and cast using they were covered with light-cured
cobalt chrome alloy (Wironit extra composite. The occlusion and fit of
hard, Bego, Bremen, Germany ). the denture were checked and minor
adjustments made to assure stability
At the final appointment, the cover and optimal function.
screws were removed and the Osfix
Bar screwed onto the implants with
Page - 164
2.2.5 Follow up YOU ARE IN:
placement cavity
bone
regrowth (-)
crestal bone level
zero point
bone loss (+)
Page - 165
2.2.6 Statistics
The bone defects were measured in bone defects from the baseline
on the mesial and distal side of were calculated. A Wilcoxon Signed
each implant. This implied that at Rank test was used to compare the
each follow-up visit there were 6-8 results between different time points.
measurements to be taken for each The analysis of variance (ANOVA) was
patient. This information was used to study the effects of gender,
summarised by calculating two annual age and number of implants 2 years
summary statistics for each patient: after implantation. SPSS (Version 10.0)
the mean bone defect and the was used for the statistical analyses.
maximum bone defect. The changes P-values less than 0.05 were considered
statistically significant.
2.3 Results
2.3.1 Success rate
Of the 203 implants inserted, 143 were lost. The 3-year success rate of Osfix
analysed during the 2-year and 62 implants was 100 %. The mean marginal
during the 3-year follow-up periods. bone loss per patient was 0.58 mm
After 3 years, no implants had been (SD=0.5) after 3 years evaluation
No. of patients 57 45 40 18
0.06 *
0.43 *
p-value
Page - 166
YOU ARE IN:
PART I: Clinical
The Maximum bone defect (mm) per patient. PART II: Laboratory
0 year 1 year 2 years 3 years PART III: Hygiene
No. of patients 57 45 40 18 PART IV: Sedation
Mean 0 1.66 1.56 1.88
PART V: Studies
Median 0 1.54 1.54 1.54
ANIMAL STUDY
SD 0.63 0.88 1.03
CLINICAL STUDY
Min 0.77 0.00 0.77
FOLLOW-UP STUDY
Max 3.85 4.62 4.62
OVERLOADING
* Wilcoxon Signed Rank Test
COATING
0.83 *
0.48 *
p-value
50
40
30
%
20
10
0
-6 -2 -1 0 1 2 3 5
Bone loss Page - 167
When comparing the different groups significant (p=0.035), but the
of patients, a low statistical significant maximum bone defects were not
difference in bone loss between men related to age (p=0.56) (lower table
and women was noted (p=0.06) (upper below). The amount of inserted
table). However, the results are not implants was not related to growth
as hypothesised. The relationship of bone defects (p=0.58) (table in
between age and bone loss was next page). Only 2 years’ results are
contradictory. In the younger age presented in these tables and because
group the mean bone defects were the low number of patients in the 3rd
deeper and the finding was statistical year did not permit statistical analysis.
Page - 168
YOU ARE IN:
Bone defects (mm) and number of inserted implants after 2years. PART I: Clinical
PART II: Laboratory
Number N Mean SD Effect of the
of number of PART III: Hygiene
implants implants p-value
PART IV: Sedation
Max. bone defects 3 17 1.36 0.79 p=0.22
PART V: Studies
4 23 1.71 0.93
ANIMAL STUDY
Mean bone defects 3 17 0.43 0.45 p=0.58
CLINICAL STUDY
FOLLOW-UP STUDY
OVERLOADING
2.4 DISCUSSION COATING
Page - 170
Karlsson et al. (1998) has studied period. This result is in agreement with YOU ARE IN:
maxillary and mandibular fixed partial the other above-mentioned studies
dentures supported by implants for (Table on previous page). There was no
PART I: Clinical
2 years. He has evaluated the clear significant difference in marginal PART II: Laboratory
difference between two different bone loss related to gender, and
implant surfaces: machined and TiO- men’s more frequent use of tobacco PART III: Hygiene
blasted. The amount of installed may explain this minimal difference.
PART IV: Sedation
implants was 133. When the results Nor could the difference between
of both implants and jaws were age groups be clearly related to the PART V: Studies
combined, the marginal bone loss growth of bone defects after 2 years
ANIMAL STUDY
was 0.24mm (SD=0.69) after 2 years follow-up. However, no differences
follow-up. No statistically significant were found related to the number of CLINICAL STUDY
difference was found between studied inserted implants. FOLLOW-UP STUDY
implant types. Wannfors, with his
OVERLOADING
co-workers (1999), has studied single This study confirms earlier studies,
implant restorations. Eighty implants which describe implant treatment as COATING
were inserted and only 1 implant was a safe method with few surgical
lost during the 3-year follow-up period. complications and minimal marginal
The average marginal bone loss was bone loss. The complications caused
0.48mm during the evaluation period. by poor structure of the prostheses
were rare, but good oral hygiene is
In the Osfix clinical study the mean considered to be a very important
marginal bone loss was 0.58mm factor in the success of implant
(SD=0.5) after a 3-year evaluation treatment.
2.5 CONCLUSIONS
The complication level was very low period. No implants were lost; hence
when inserting Osfix implants. The the success rate of the Osfix implant is
mean bone loss per patient was 100 % after 3 years follow-up in 1999.
0.58mm during the 3-year observation
2.6 ACKNOWLEDGEMENT
We wish to extend our gratitude to with the statistical analysis.
Mrs. Tuija Poussa for her assistance
Page - 171
REFERENCES
Babbush C, Shimura M : Five year Lindquist L , Carlsson G, Jemt T : A
Krogh P, Polizzi G, Zarb G, Herrmann I : system implants used for single tooth
5-year multicenter study. Int J Oral Oral Implants Res 1996 : 7 : 162.
Page - 172
YOU ARE IN:
PART I: Clinical
PART II: Laboratory
FOLLOW-UP STUDY: PART III: Hygiene
1 Osfix International Ltd Oy, P.O. Box 14, FIN-47201 Elimäki COATING
3.1 ABSTRACT
The purpose of the study was to determine the effects of implantation on the
quality of life and to obtain information on the oral home care of patients. The
subject group were patients who had received implants and a Dolder-type bar
construction for a mandibular prosthesis, and who had a traditional removable
prosthesis on the maxilla. The questionnaire was mailed to 58 people. Forty-nine
questionnaires were returned, representing a reply rate of 84 %.
Implantation did have an effect on the patients’ quality of life. The patients
considered their present mandibular and maxillary prostheses significantly
better than those they had used previously. They were particularly satisfied
with the prostheses on the mandible. Those patients who replied considered
the present prosthesis on the mandible better than those they had used
previously(p<0.0001). The prosthesis on the maxilla was also regarded as
considerably better than those they had used previously(p<0.0001). The main
benefit resulting from implantation was the ease of laughing and mastication.
The oral home care of implant patients had worked out well. The patients felt
confident with the various cleaning methods used in their oral care, and they
considered themselves able to clean both the bar and the prostheses well. The
most common cleaning aids were the toothbrush and interdental brush, which
were used on average twice a day.
Page - 173
3.2 INTRODUCTION
Traditional dentures are often of implant treatment. To maintain
considered cumbersome and a healthy tissue, careful removal of
unpleasant; some people never get plaque around the implant is essential.
used to them. Implant treatments Plaque causes gingivitis and bleeding
offer solutions for many problems in the same way as it does in the tissue
caused by the use of prostheses around a natural tooth. To maintain
(Salonen 1996; Hujanen 1996). Users oral health, the care of an implant
do not feel comfortable as they need patient includes cleaning at home and
to think about how to keep the regular appointments at a dental clinic
prosthesis in place. Everyday functions (Torres 1995). To secure the success
such as eating, laughing and speaking of home care, it is important that
may cause a feeling of insecurity the patient is confident with the oral
(Seddon and Smith). The poor stability cleansing methods (Babbush 1991;
of the prosthesis may also cause Spindler 1999). Because efficient oral
sore pressure cuts on the mucosa cleansing has a direct effect on the
(Laine and Lindqvist 1996). Implant success of the implant treatment, the
treatments offer a solution for many role of the medical staff in patient
of the problems caused by the use guidance is enhanced (Seddon and
of prostheses (DuCoin 1996; Myers Smith). When choosing the cleansing
Kracher and Schmeling Smith 1998). aids, the main emphasis should be
Long-term implant treatment requires, simplicity in use and the minimum
in addition to successful ossification number of implements, as an excessive
and a well planned and executed number of articles may be considered
prosthesis structure, satisfactory oral cumbersome (Myers Kracher and
hygiene (Talonpoika and Uusitalo 1997). Schmeling Smith 1998).
Oral home care is an important part
The purpose of the study was to information on the oral home care of
determine the effects of implantation patients.
on the quality of life, and to obtain
Page - 174
3.3 PATIENTS AND METHODS YOU ARE IN:
PART I: Clinical
Anonymous questionnaires were sent two of the questions metering VAS-
to 58 patients who had received change, and three being multi-choice PART II: Laboratory
implants and a Dolder-type bar questions.
construction for a mandibular
PART III: Hygiene
prosthesis, and who had a traditional The patients’ experiences of
PART IV: Sedation
prosthesis on the maxilla. Forty-nine prostheses and their ability to care
questionnaires were returned, for the them was measured with VAS PART V: Studies
representing a reply rate of 84 %. No technique (length of line 10 cm).
ANIMAL STUDY
reply was disqualified. Of the answers The results are given as medians and
received, 32 were from women and ranges. A Wilcoxon signed ranks test CLINICAL STUDY
17 from men. The age of the subjects was used to compare the variables, FOLLOW-UP STUDY
ranged between 40-82 years. and Spearman rank correlations were
OVERLOADING
calculated to study the associations
The questionnaire consisted of 25 between these variables. COATING
questions, of which 3 were open
questions, 3 opinion-based questions The box plot figures were drawn to
to be measured with a linear meter describe the distributions of variables.
(VAS: Visual Analogy Scale), and the The box represents the interquartile
remaining part structured questions range and the whiskers indicate the
(Statements with Likert scale, “yes-no” highest and lowest values, excluding
questions and multi-choice questions). outliers. A line across the box indicates
There was also a question on the the median. SPSS (Version 9.0)
subject’s sex and year of birth. statistical program was used for
statistical analyses.
This report concentrates on analysing
the questions concerning the quality
of life and oral hygiene at home,
Page - 175
3.4 RESULTS
The patients’ experiences of present All subjects considered their present
prostheses were good. They found mandibular prosthesis better than
great relief for many functions their previous one (p<0.0001). The
involving the use of the mouth. prosthesis on the maxilla was also
The main change brought about by considered substantially better than
implantation was felt to be easier the previous one (p<0.0001). Fifty-
laughing and mastication. Speaking four percent (26/48) of the patients
and social interaction were also estimated the present prosthesis on
considered more comfortable. the maxilla better than the one they
had used previously.
Effects of
Implantation on positive no effect negative For 42 %, the status
in the maxilla
Speech 37 10 2
remained the same
Mastication 48 1 0 (20/48). Only 4 % (2
patients) felt their
Appearance 31 17 1
previous prosthesis
Interaction 43 6 0 had been better. The
Laughing 48 1 0 VAS changes have
been presented in
figure below.
Patients’ experiences on previous and present mandibular and maxillary protheses (VAS
0=very poor, , 10=very good) and their desire for implant fixture of the maxillary prosthesis
(VAS0=desire, 10=great desire).
A B C D E
Explanation of the colums in figure: A) satisfaction in the previous maxillary prosthesis B)
satisfaction in the previous mandibular prosthesis C) satisfaction in the present maxillary
prosthesis D) satisfaction in the present mandibular prosthesis E) desire for implant fixture
for the maxilla.
Statistical significances:
A=> C : p < 0.0001* B => D : p<0.0001*
CLINICAL STUDY
The oral home care of the patients was satisfactory, whereas the ability FOLLOW-UP STUDY
had been carried out well. The bar that to use other cleaning aids varied OVERLOADING
was fitted on the implants was cleaned considerably.
COATING
sufficiently frequently. Toothbrushes
and interdental brushes were the most The patients considered themselves
commonly used tools for this. The able to clean both the bar and the
patients felt most confident with prosthesis well. They felt, however,
the toothbrush and prosthesis brush. that they could clean the prosthesis
The use of the interdental brush better than the bar (p=0.002).
number
of replies 23 34 10 10 33 22 0 0
Page - 177
3.5 DISCUSSION
Implantation had a positive effect It is essential that the implant
on the patients’ quality of life. They prosthesis patient is meticulous about
felt their present prostheses were their oral home care, both in quality
much better than their previous ones. and frequency. Daily oral hygiene
Particular improvement was felt with includes the cleansing and examination
the mandibular prosthesis. Some need of the bar structure, prostheses and
was also felt to fix the maxillary mucosa. Special attention must be paid
prosthesis on implants. The main to the cleansing of the bar structure.
changes felt after the implantation As the mandibular prostheses may be
were easier laughing and mastication. unfastened, visibility of the implant-
The patients’ experiences on the fixed bar is improved and its cleansing
improvement of oral functions as is facilitated (Lawrence 1991). Oral
a result of implant treatment were home care was carried out well among
similar to those stated in previous the subjects. They cleaned the bar
studies (Ducoin 1996, CibIrka et al. sufficiently frequently and with the
(1997), Myers Kracher and Schmeling right methods, which is essential for
Smith 1998). In addition to the changes the success of the implant treatment.
mentioned above, the patients felt In addition to this, it is important that
their appearance had improved, their they considered oral hygiene to be
speech had become easier and their important and were interested in their
interaction with other people had personal oral hygiene. On the whole,
become more pleasant. In addition to the patients felt confident with the
functional benefits, the requirements new cleansing methods.
of the patients for factors increasing
social interaction are considered
important (Myers Kracher and
Schmeling Smith 1998).
3.5.1 CONCLUSIONS
Page - 178
REFERENCES YOU ARE IN:
Babbush C : Dental Implants : Myers Kracher C, Schmeling Smith W : PART I: Clinical
principles and practice. W. B. USA: Oral health maintenance of dental
implants: A Literature Review. The
PART II: Laboratory
Saunders Company 1991.
Dental Assistant 1998 : 2-14. PART III: Hygiene
Cibirka R, Razzoog M, Lang B : Critical
evaluation of patient responses to Salonen S : Implanttiprotetiikka PART IV: Sedation
dental implant therapy. J Prosth Dent (Implant prosthetics). Meurman J,
PART V: Studies
1997 : 78 : 574-581. Murtomaa H, Le Bell, Y, Autti H.,
Luukkanen M. (editors) Therapia ANIMAL STUDY
DuCoin J : Dental implant hygiene and odontologia. Forssa: Academica CLINICAL STUDY
maintenance. Home and professional kustannus 1996.
FOLLOW-UP STUDY
care. J Oral Impl 1996 : 22 : 72-75.
Seddon I, Smith K : The hygienist´s OVERLOADING
Hujanen E : Prosthetics of the role in an implant practice. Dental
COATING
edentulous mouth (in Finnish). In: Health 1998 : 37 : 5-7.
Meurman J, Murtomaa H, Le Bell
Y, Autti H, Luukkanen M (editors) : Spindler J. 1998. How should dental
Therapia odontologia. Forssa, Finland: implants be maintained? http:/
Academica Kustannus 1996. /ourwold.compuserve.com/
homepages/perio-horizons/
Laine L, Lindqvist C : Preproteettinen pg3.HTM.20.1.1999.
kirurgia ja implantologia (Pre-
prosthetic surgery and implantology). Talonpoika J, Uusalo E : Maintenance
In: Meurman J, Murtomaa H, LeBell care of the implant patient (in
Y, Autti H, Luukkanen M. (editors) : Finnish)). The Finnish Dentists’ Journal
Therapia odontologia. Forssa, Finland: 1997 : 7 : 327-375.
Academica Kustannus 1996.
Torres E : Modern dental assisting.
Lawrence L : Oral hygiene for dental W.B. USA: Saunders Company 1995.
implant patients. Texas Dental J 1991 :
108 : 21-23.
Page - 179
Page - 180
The Behaviour of OSFIX Implant YOU ARE IN:
Components in Overload PART I: Clinical
Situations
PART II: Laboratory
Luotio K., DDS, PhD 1, Jatkola S. Dent Techn2, Halonen T. Dent Techn2, Lappi T. PART III: Hygiene
Dent Techn1, Hanhela M., MSc1
PART IV: Sedation
1 Osfix International Ltd P.O. Box 14, FIN 47201 Elimaki, Finland
PART V: Studies
2 The Helsinki Polytechnic, Finland ANIMAL STUDY
CLINICAL STUDY
4.1 ABSTRACT
FOLLOW-UP STUDY
The purpose of the study was to determine the effects of overloading on OVERLOADING
BiOsfix single tooth implants and the prosthetic screws joining the crown and the
COATING
implant. The implants and the screws were submitted to fatigue and fracture
resistance tests with appropriately designed equipment. The screw material was
both grade 2 and grade 4 titanium and the implants were made of grade 2
titanium. Observations were made on the differences between the different
grades on the basis of the tests.
In an overload situation, the screws acted as fuses, breaking at the safety groove
and protecting the implant from damage. Even in the fatigue test, the screws
resisted hundreds of thousands of 200 N cycles. The number of cycles needed
to break the screws was 150,000 ->850,000, by which time 6 out of 11 screws
tested had broken (range 150,000 - 300,000).
In emergency situations the implants bent, whereas the fatigue test did not
inflict any changes.
On the basis of the tests it can be stated that in an overload situation the implant
and the prosthetic screw will yield at the planned point, and that the grade 2
titanium used as implant and screw material is sufficiently strong and flexible,
even in emergency situations.
Page - 181
4.2 INTRODUCTION
One of the possible complications of in the transverse direction caused
implant treatment is the occurrence the highest bending moments in the
of an implant fracture. Biomechanical implant and the surrounding bone.
overload and metal fatigue are the These were 4 to 5 times greater
most common causes of fractured than the bending moments in a
implants. (Piattelli et al. 1998) Clinical mesiodistal direction. Horizontal forces
studies indicate that loosening or are transmitted via a lever arm,
fracture of implant prostheses occurs creating bending moments.
in 5 to 45 % of cases during the first
year. The nature of the loosening of In his study, a specially designed
prosthetic components is complicated, load cell was placed directly in the
since it involves cycling fatigue, oral implant permitting the measurements
fluids and varied chewing patterns and of bending moments. The transverse
loads. (Sakaguchi & Borgersen 1995). loads during chewing resulted in the
Implant fractures can cause significant highest bending moments of 170
problems. Some researchers suggest Nmm max. and the highest stress in
that these problems could be related the bone was 6.2 MPa at the crest on
to prosthetic and functional stresses the buccal side. The mesial bending
associated with progressive bone loss. is not critical (52 Nmm mean max.
(Zarb & Schmitt 1990 and Rangert & moment).
Forsmalm 1993). The fact remains that
chewing and maximum bite forces Richter (1995) also studied in vivo
differ widely between individuals. vertical forces on implants during
oral functions. Implants in the molar
Richter (1998) investigated the in position that were fixed to a premolar
vivo horizontal bending moments on with a prosthesis withstood maximum
implants. vertical forces of 60 to 120 N during
chewing. Single molars and premolars
An implant in the molar position that carried maximum vertical forces of
is connected to a mesial tooth by 120 to 150 N. The high stress areas
a prosthesis is loaded by vertical are located at the implant’s neck
and horizontal forces during any oral (Siegele 1989). Implant fractures may
function. Vertical loads are transmitted be a result of implant design and
directly to the bone around the manufacturing, non-passive fit of the
implant. The most important result framework or biomechanical overload
of his study was that chewing loads (Balshi et al. 1996).
Page - 182
YOU ARE IN:
PART I: Clinical
PART II: Laboratory
PART III: Hygiene
crown PART IV: Sedation
PART V: Studies
ANIMAL STUDY
prosthetic screw
CLINICAL STUDY
FOLLOW-UP STUDY
implant
OVERLOADING
COATING
Page - 183
4.4 MATERIALS AND METHODS
Materials used:
Cobalt chrome alloy (REMANIUM Titanium
2000):
Quality: grade 2 grade 4
Cobalt Co 0.61
Mechanical work:
Tested items:
Implants
The tests were made on dental the implant is intended mainly for
implants developed by Osfix replacing single teeth. Bridge
International Ltd to be placed in the structures for two implants can also be
bone. The dental implant, made of fabricated. The product classification
titanium (grade 2), is a cylindrical is 2B (MDD Annex 9 implanted items).
structure with apical thread and The main and critical forces against
internal rotation check (internal the structure are received by the level
hexagon). The surface of the implant or buffer surface of the implant.
has been mechanically coarsened and
Page - 184
Prosthetic screws YOU ARE IN:
CLINICAL STUDY
FOLLOW-UP STUDY
OVERLOADING
The crown
Fatigue test
Equipment
The jaws were set for light chewing continued in the same way until the
and they were burdened as follows: 1,000,000 limit.
five implants with rounded edges were
strained 1,000,000 times/structure. When the one million concussion limit
Repetitions were made twice a second was reached, the acrylic was removed
by pressing the parts together from around the implant. For the next
occlusally at 200 N. The fatigue was implant, retentions were made in the
continued until a prosthetic screw hole thus created. A new implant was
broke. The test was then paused and, fitted in place of the previous one
after changing the screw, the test was with a silicon index, and new acrylic
was poured around the implant. The
acrylic was hardened as above.
Analysis
The fracture surfaces appearing in the Philips XL-20, with an EDS analysator
prosthetic screws were observed with (manufacturer EDAX).
a scanning electron microscope (SEM),
The test equipment was Zwick Z250 resistance test. The superstructure
stress device/meter. A suitable implant of the implant was always the same
holder as well as a presser piece cobalt chrome structure that was also
was manufactured for the fracture used in the fatigue test.
Testing
The test was made on the same widest part beginning at the implant
implants as in the fatigue test, as socket. The presser piece struck
they remained unbroken. To fasten the directly on the titanium prosthetic
cobalt chrome structure, two different screw that emerged from a hole in
types of prosthetic screws were used: the cobalt chrome structure. The test
grade 2 and grade 4. had to be made with the palatinal
side of the cobalt chrome structure
The implant holder was tightened to uppermost, as the facial surface was
enable the presser piece to strike the too round.
structure from above, 10mm from the
Page - 186
Analysis YOU ARE IN:
PART I: Clinical
The results of the test were recorded resistance or the greatest force that
on the equipment’s computer, from finally broke the screw. The device also PART II: Laboratory
which the desired information could gave the lower yielding limit, or the
be obtained as figures or graphs. For point at which permanent change in
PART III: Hygiene
the test, the equipment was adjusted the metal was detected.
PART IV: Sedation
to gather information on fracture
PART V: Studies
4.5 RESULTS ANIMAL STUDY
CLINICAL STUDY
Implants
FOLLOW-UP STUDY
In the fatigue test no changes were In the fracture resistance test, all OVERLOADING
observed in the implants, so the five implants bent where the
COATING
implant itself survived the one million superstructure joins the implant.
concussions limit.
Prosthetic screws
Figure
The 3. Electron microscope
electron microscope picture of the fracturefracture
pictures, surface of surfaces
the screw after
on the
thefatigue test. area
yielded
taken after the fatigue test, show have long crystal structures, appearing
that the titanium prosthetic screws to be stretched and parallel. Before
have slowly given in to fracture. The breaking they have undergone final
FINAL POINT OF
FRACTURE
Page - 187
fracture which is rough and small was between 239.48-261.94 N and
structured. The number of cycles for grade 4 alloy 289.39-302.53 N
(upper table below) needed to break respectively (lower table below). The
the prosthetic screws was 150,000 results show that grade 4 alloy is ca.
-> 850,000, at which point 6 out 20 % stronger. It was also observed
of 11 tested prosthetic screws had in the graphic curves that grade 4
broken (range 150,000 - 300,000, could better resist bending. Grade 2
mean 263,333). alloy screws bent 3.40-3.93 mm before
breaking. The bend in grade 4 alloy
The fracture resistance curves were was 2.44-2.69 mm.
similar in structure for both grade
2 and grade 4 titanium prosthetic Breaking point: All broken prosthetic
screws (figures next page). The screws broke along the safety groove
fracture resistance for grade 2 alloy both in the fatigue test and in the
fracture resistance test.
1 150,000
2 300,000
3 280,000
4 290,000
5 280,000
6 280,000
mean 263,333
2 1 261.64 3.93
2 2 239.48 3.40
2 3 253.52 3.74
4 1 289.39 2.69
4 2 302.53 2.44
4 3 301.76 2.55
CLINICAL STUDY
FOLLOW-UP STUDY
OVERLOADING
COATING
b) grade 4 titanium
b) grade 4 titanium
b) grade 4 titanium
Page - 189
4.6 DISCUSSION
The purpose of the study was to implant would be entirely removed
determine the effects of overloading when the screw bends.
on BiOsfix single tooth implants and
the prosthetic screws joining the When we observe the durability of
crown and the implant. On the basis the screw when subjected to chewing
of the tests, the durability of BiOsfix loads, we can state the screw is
implant material during chewing was sufficiently strong. In the test the
evaluated, as well as the safety of screws and implants were burdened
the implant in a possible concussion with 200 N for hundreds of thousands
situation. of cycles. The bending moments on
the implant during chewing usually
In an overload situation, the screws remain at a maximum of 170 N (Richter
acted as “fuses”, in that they gave 1998). It has to be noted, however,
way and thus protected the implant that chewing forces differ widely
from damage. Even in the fatigue between individuals. Mericske-Stern et
test, during which the screws were al. (1995) made a comparison between
subjected to a force of 200 N, the maximum chewing forces of implant
screw endured hundreds of thousands patients. The chewing forces on an
of cycles. In an overload situation implant-supported, fixed prosthesis
the screw broke at the correct point varied between 200-300 N. The force
or along the safety groove, which is, however, shared by several
facilitates the repair of the implant implants.
structure. A comparison of the fracture
resistance graphs between grade 2 and In an emergency situation, the implant
grade 4 titanium qualities shows that showed distortion between the
grade 2 titanium has lower fracture superstructure and the implant. This
resistance, but bends more before damage could, nevertheless, in most
breaking than grade 4. This makes cases be repaired with burn-out
it safer in a concussion situation components. On the other hand, the
(violence, accident), as it would be less fatigue test created no changes in the
likely that the superstructure of the implant.
4.7 CONCLUSIONS
On the basis of the tests it can overload situation, and that the grade
be stated that the prosthetic screw 2 titanium used in both implants and
will yield at the planned point in an prosthetic screws is sufficiently strong
and elastic in an emergency situation.
Page - 190
REFERENCES YOU ARE IN:
Balshi T, Hernandez R, Pryszlak M, Richter E : In vivo horizontal bending PART I: Clinical
Rangert B : A comparative study of moments on implants. Int J Oral
Maxillofac Implants 1998 : 13 : PART II: Laboratory
one implant versus two replacing a
232-44.
single molar. Int J Oral Maxillofac PART III: Hygiene
Implants 1996: 11: 372-378.
Sakaguchi R, Borgersen S : Nonlinear PART IV: Sedation
Mericske-Stern R, Assal P, Mericske E, contact analysis of preload in dental
implant screws. Int J Oral Maxillofac PART V: Studies
Burgin W : Occlusal force and oral
tactile sensibility measured in partially Implants 1995 : 10 : 295-302. ANIMAL STUDY
edentulous patients with ITI implants. CLINICAL STUDY
Int J Oral Maxillofac Implants 1995 : Siegele D : Numerische
Untersuchungen zur Optimierung der FOLLOW-UP STUDY
10 : 345-53.
durch Zahnimplantate bedigten OVERLOADING
Piattelli A, Scarano A, Piattelli M, Beanspruchung des Kieferknochens.
COATING
Vaia E, Matarasso S : Hollow implants Thesis. Fraunhofer-Institut für
Page - 191
Page - 192
YOU ARE IN:
PART I: Clinical
PART II: Laboratory
PART III: Hygiene
PART IV: Sedation
PART V: Studies
COATING:
ANIMAL STUDY
K. Luotio, DDS, PhD 1, 2, T. Stenberg PhD,3, P. Vuoristo, PhD 3, T. Mäntylä Prof. OVERLOADING
PhD 3 and R.M.Kotilainen, Prof. DDS, PhD 2 COATING
5.1 ABSTRACT
Three different coatings for cast CoCr -alloy dental implant frameworks were
studied. Coatings were approx. 1 mm thick TiN+Ti - and Ti+TiN -double layers
and Ti+DLC gradient structure film manufactured with PVD deposition methods.
The corrosion resistance of these films was studied with immersion tests,
electrochemical polarisation tests and by measuring the amount of dissolved
metal ions. The corrosive medium was a physiological saline solution. The
structures of the films were studied with a scanning electron microscope (SEM).
All the films studied provided good corrosion protection and the amount of
dissolved Co-ions was reduced by up to 90 % compared to the base material.
This reduction may have important clinical significance in cases of allergy to
the components of CoCr-alloy and in cases where there is a need to enhance
biocompatibility.
Page - 193
5.2 INTRODUCTION
Dental implant frameworks (i.e. mesio- mentioned studies, all cobalt chrome
and super-structures) are alloy components may also dissolve in
conventionally made of gold alloys. oral conditions. Galvanic corrosion has
However, mainly for economic reasons, been claimed to cause loss of bone
cobalt chrome alloy is an interesting around the implant (Adell et al. 1981,
material for the same purpose. Cobalt Geis-Gerstorfer et al. 1989). The clinical
chrome alloy is commonly used in follow-up made on implant prostheses
prosthodontics and it is a well-known does not, however, support this claim
material by both dentists and dental (Hulterström et al. 1994, Luotio 1997)
technicians. One of the disadvantages but the loss of bone is at the same
of cobalt chrome alloy is its hardness, level as with gold-based structures
which makes the material difficult (Alberektsson et al. 1986, Knotek
to handle in a dental laboratory. et al. 1992). To produce a coating
Possible allergic reactions to cobalt on cast CoCr-alloy seems to be a
chrome should also be considered, more practical and economical method
even though they are extremely rare to achieve more corrosion resistant
(Moberg 1958, Stenberg 1982, implant frameworks than producing
Kotilainen 1991). Nevertheless, all e.g. a titanium prosthesis. The casting
structures must be designed to enable of titanium requires considerably more
the removal of cobalt chrome alloy complex technology including a
components from implant and dental protective gas atmosphere.
structures. According to the previously
2) to investigate if it is possible to
decrease the solubility of cobalt
chrome components with thin film
technology.
Page - 194
5.3 MATERIALS AND METHODS YOU ARE IN:
PART I: Clinical
5.2.1 Film deposition
PART II: Laboratory
Three different thin films were studied. temperature. The base material was
Ti-DLC (Diamond-Like Carbon) film with cast CoCrMo alloy (Wironit extra hard, PART III: Hygiene
a gradient structure from pure Ti Bego, Germany), with a nominal
to pure DLC was made by DIARC- composition of Co 63; Cr 30; Mo
PART IV: Sedation
Technology Oy, Helsinki, Finland, with a 5; Si 1.1; Mn 0.5; C 0.4. The test PART V: Studies
pulsed carbon plasma arc PVD method. plates were custom made and hand
ANIMAL STUDY
Two double layer films, TiN-Ti and Ti-TiN, polished using methods standard in
were made by Surfcoat Oy, Mikkeli, dental laboratories. The size of the CLINICAL STUDY
Finland, by unbalanced magnetron test plates was A=4 cm and thickness
2
FOLLOW-UP STUDY
sputtering. The studied thin films and 0.5 mm. The films are denoted below
deposition methods are given in table according to the top layer of the films OVERLOADING
below. In both techniques, deposition as marked in table below. COATING
was made in a vacuum at room
5.3.2 Characterisation
The microstructural studies of the films The coating thickness was determined
were carried out with a Philips XL30 from the SEM micrographs.
scanning electron microscope (SEM).
DLC-film:
The film composition changes gradually the upper half of the film, when the
from pure titanium to diamond-like amount of the DLC is more than 50 %
carbon structure. When the film and they are macro-droplets from the
thickness during deposition reaches process. The pores are mainly situated
the value of 400-500 nm, the near the agglomerates and so they are
morphology of the film changes, this also present only within the upper half
can be seen in the SEM-micrograph. of the film. The average pore size is
The total thickness of the film is app. approx. 200 nm.
1 mm. Some porosity can be seen on
the surface of the film as well as some
macro particles. These are formed in
Page - 196
TiN-film: YOU ARE IN:
In the sputtered Ti/TiN film, the inner layer was 1 mm. The cross-section of PART I: Clinical
layer of Ti works as an adhesion- the film is very smooth and dense,
enhancer for the subsequently but some porosity can be seen on the
PART II: Laboratory
deposited layer of TiN-film. The surface. The pores are mainly located PART III: Hygiene
thickness of the Ti layer is aprox. 150 on the scratches left from the grinding
nm. The thickness of the outer TiN of the base material. PART IV: Sedation
PART V: Studies
ANIMAL STUDY
CLINICAL STUDY
FOLLOW-UP STUDY
OVERLOADING
COATING
Ti-film:
The thickness of the inner TiN layer to wear and mechanical damage. The
is app. 1 µm. The outer layer of TiN is formed into a slightly columnar
Ti is 200-300 nm thick. The hard structure, but the Ti-layer seems to be
TiN beneath gives support and load- very dense. Adhesion between TiN and
carrying properties to the thin Ti top Ti layers is good. Some porosity is seen
layer and makes the film more resistant on the surface, but less than on the
surface of Ti/TiN -film.
Page - 197
5.3.2 Corrosion tests
Ti-film 0.0
DLC-film 0.1
Page - 198
5.4.2.3 Measurements of dissolved ions YOU ARE IN:
PART I: Clinical
In order to have more information and the most corrosion resistant, since
on the protective behaviour of the the smallest amounts of Co and Cr were PART II: Laboratory
coatings, the dissolved metal ions in detected in the solution. When Ti-film
the corrosive media were measured. was used, the amount of dissolved Co PART III: Hygiene
Diluted into the liquid, the cobalt was was reduced to 9 % of that detected
PART IV: Sedation
found to dissolve at much higher for uncoated CoCr-alloy. With DLC-film
rate (nearly 3 times faster) than the the amount of Co was reduced to PART V: Studies
chromium from the base material. No 30 % and with TiN-film to 60 % of the
ANIMAL STUDY
other ions from the cast alloy were uncoated alloy. The results are shown
detected. Some traces of dissolved Ti in table below. These results reveal that CLINICAL STUDY
ions were detected from the TiN film, the sputtered Ti-film gives a higher FOLLOW-UP STUDY
indicating some extent of dissolution protection than the TiN-film prepared
OVERLOADING
in the film. From the studied materials, by the same coating process.
the Ti-film seemed to be the densest COATING
metal ions, ppm Cr: 5.14 Cr: 0.24 Cr: 0.74 Cr: 1.61
after 24 hours Co:8.7 Co: 1.31 Co: 2.2 Co:4.41
metal ions, ppm Cr:5.37 Cr: 1.12 Cr: 2.65 Cr: 4.6
after 72 hours Co:14.68 Co: 2.5 Co: 4.49 Co: 8.49
All the examined materials have been documented Kornu et al. (1996) using
accepted as highly biocompatible in both cell culture and animal tests.
medical literature. Titanium has been
used as implant material for over 30 In dental use, if not implanted, the
years and TiN coating is in common use only theoretical channel for systemic
and produced for dental applications effects is the digestive canal. The
by one Danish company (Gradjean question is academic, not practical,
1995) at least. From a clinical point because large amounts of diamond
of view, the surface hardness of are swallowed for decades after every
the exposed metallic framework is dental operation as a result of the
important because calculus removal is wearing of diamond drills. Moreover,
a procedure which is highly abrasive diamond is carbon which has been
and potentially damaging. Thus the used as a medicine for centuries.
DLC is the most interesting material.
When coatings are used in dental
Moreover, it is in common use in
prostheses, we have to accept that
heart valve prosthesis (Elizondo et
these frameworks are not serial
al. 1996, Monties et al. 1997) and
products, but custom made. Thus the
under consideration for hip prosthesis
structures always contain areas which
Nordsletten et al. (1996). The
are not perfectly polished and the
biocompatibility of DLC is well
behaviour of the coating material in
such surfaces needs further study. Page - 199
5.4.4 Conclusions
All the studied films were slightly surgical drills. This study showed that
porous due to the coating processes. the use of TiN may no longer be the
Surface scratches were found to be best material for the purpose, because
the preferred sites for pore formation. we now have better alternatives.
The structure of the sputtered Ti-layer
seemed to be the densest of these The other facts affecting the choice
studied films whereas TiN tended to between these films are hardness,
form a slightly columnar structure. coverage of the coating if complex
The DLC film contained some small shape frameworks are coated,
agglomerates within the upper half of availability of the coating and cost.
the film. Both Ti and DLC are promising coatings
to prevent CoCr ion release and the
All the coatings were able to reduce hardness of the surface of DLC makes
the amount of dissolved ions from it most interesting. The problem of
the base material. The reduction of DLC is that the gradient process with
dissolved Co-ions was from 40 to 90 %. titanium is not in common use and the
The lowest reduction was observed commonly used process with tungsten
in TiN coating which is in common does not produce stabile coatings for
use for decreasing the corrosion of biocompatible use.
5.4.5 Acknowledgements
We would like to thank Professor Jouni are very grateful for the dedicated
Tummavuori from the University of handwork of Ms. Satu Luukkainen,
Jyväskylä, Finland, for valuable help in dental technician, in producing and
the chemical analyses. In addition we polishing the plates.
Page - 200
REFERENCES Schleimhautbeschwerden mit YOU ARE IN:
Referenz zu methodischen Aspecten
Adell R, Lekholm U, Rockler B,
in allergologischer Sicht. GOI
PART I: Clinical
Brånemark P : A 15-year study
Jahrbuch, Quintessenz 1991: 237-241. PART II: Laboratory
of osseointegrated implants in the
treatment of the edentulous jaw. Int J
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KEYWORDS:
Dysmorphophobia......36
A Acrylated ....................23
Agonists......................125 E Endodontal .................35
Ambu ..........................130 Endosteal....................35
Analysator...................186 Endothracheal ............130..143
Anesthesiological........143 Ethylic .........................54
Angulating ..................49 Etilephrine ..................131
Angulation ..................75 ...81 ...163
Anteriorically...............23
Anterograde ...............128 F Facebow .....................69 ...163
Fb-Glu .........................38
Antigenes ...................33
Felypressin..................54
Anxiolytes ...................128
Fibrointegration .........34
Anxiolytic ....................125..126
Flumazenil...................117..126..130
Apatite ........................17....33
137..138 .139
Apposed .....................157
Formaline ...................152
Aseptics ......................152
Fossa...........................122..123..138
B Benzodiazepines .........117..121..122
G Galvanostat.................195
123..124..125
Galvanous ...................16
127..129 .130
Gastroenterological ....126
131..133..135
Gingiva ........................99 ...106 .107
137..138 .139
108 .110..111
141..143
114
Biocompatibility .........193..199
Glycosaminoglycans....33
Biocompatible ............194 .199 .200
Biomechanical ............82 ...182
Buccal .........................63 ...182 H Haematoma ................123
Buccally ......................79 Haemostasis ...............54
Handpiece...................50 ...53 ...54
68 ...73 ...75
C Chlorhexidine .............114
Handwash ...................52
Calcitonin....................33
HCl ..............................195
Cancellous ..................33
Histological .................15....32 ...153
Cannula.......................123..128..129
156..158
130..135..137
Hyperbaric ..................36 ...37
138..140 .142
Hypnotics....................127
Cannulation ................53 ...123..129
Hypoxic .......................37
130..135..140
Cefalosporin ...............54
Chlorhexidine .............114 I Iatrogenic ...................81
CoCr ............................19....193..198 Indometacin ...............54
199..200 Interdental..................99 ...108 .110
Condylar .....................93 ...95 111..114..173
Condyles .....................69 ...163 177
Corallic ........................17 Interquartile ...............175
Correlations ................175 Intraoral ......................39
Crestal ........................42 ...165 Intubation...................130..143
Crista ..........................17....54 ...59 Ischemy ......................142
Page - 203
Mandibular..................42 ...54 ...81 Periosteum .................33 ...54
89 ...148 .151 Phagocytic..................34
152..170..171 Pharmacodynamics ....117..124..125
172..173..175 Pharmacokinetic.........117..124..125
176..177 .178 Phenolic......................52
Mentale.......................42 Polyxane .....................163
Mesial..........................165..166 .182 Potentiate ..................127
Mesiodistal..................182 Potentiodynamic ........195..198
Mesiostructure ...........48 ...161..164 Potentiostat ...............195
Methacrylate ..............153 Premedication ............89 ...126..128
Micrographs................195 129..144
Microstructural ...........195 Preparates ..................158
Midazolam ..................54 ...117..121 Prilocaine ....................54
126..127..128 Procain .......................152
129..131..136 Procallus .....................34
139..140 .141 Prosthodontic ............81 ...148
142 Prosthodontics ...........9 .....194
Millary .........................41 Pseudarthrosis............34
Mucoperiosteal...........163 Pseudoperiodontal.....34
Mucosa .......................17....36 ...59 Psychogenic ...............119..141..143
103..105 .106
107..108 .109
111..113..114 R Radiologically..............16....152
Radiolucence ..............32
174..178
Rebase ........................95
Mucosal.......................35
Regreasing..................61 ...73
Myastenia ...................122
Regrowth....................165
Resedation..................138
N Nalorphin ....................130 Resorbable..................57
Neuroleptics ...............128 Resorbed ....................23 ...44 ...48
Resorption ..................34 ...48 ...163
Retightened................164
O Occlusal.......................18....24 ...39
47 ...48 ...49 Retightening...............73
74....87 ...92
93 ...97 ...98 S Sagittal .......................158
99 ...191 Salbutamol .................131
Occlusally ....................186 Sedationist..................130..143
Orthopantomograms .165 Simeditine...................128
Os................................54 ...121..141 Spongious...................33 ...41 ...48
Osteoblasts .................33 ...34 158
Osteoclasts .................33 Sprue ..........................91 ...93 ...96
Osteogenic .................34 Spruing .......................87 ...93 ...95
Osteonectin ................33 96 ...97 ...98
Overdenture ...............16....24 ...48 99
87 ...89 ...91 Subcortical .................127
92 ...93 ...95 Subcutaneously ..........152
97 ...99 ...161 Subdermal ..................35
Oversedated ...............121..138 Subperiosteal..............35
Oximeter.....................39 ...52 ...53 Suppurative ................170
133..134 .135 Surfcoat......................195
136
Oximetry .....................117..131..133
134..135..140 T
Oxyhaemoglobin ........133..134
P Palatinal ......................186
Parathormone ............33
Paravenous .................135..140
Parentheral.................126
Passivated...................198
Periodontics ...............39
Periodontitis ...............36
Periosteal....................17
Page - 204
Tachycardia .................136
Thermographically......15
Threader ....................112..108
Thrombocytes ............38
Thrombocytopenia.....36
Thromboflebite ..........123
Thrombophlebitis .......126..140
Ti+DLC ........................193..195
TiN+Ti .........................193..195
Titrated.......................121..128
Toluidine .....................153
Tomograms.................40
Tomography ...............40
Toothpastes ................110
Torsional .....................47 ...48
Trabecular ...................33
Transmucosal ..............17....23
U Uncoated ....................198..199
Undersedation............121
Unresorbed.................35
Untightened ...............61
V Vasovagal....................141
W Workpiece...................93
X Xylitol ..........................107
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