SURGICAL CONSIDERATION IN IMPLANTOLOGY

Dr.Dr. Boworn Klongnoi

Treatment concepts

?
Patient driven concept ? Surgeon driven concept ? Prosthodontist driven concept ?

General in dental implant

A proper planning is important for obtaining an acceptable final result Complete treatment plan needs consultation from both surgeon and prosthodontist Surgeon should also has the knowledge of prosthodontic planning

Osteointegration

Direct bone deposition on the

implant surface without

intermediate fibrous tissue or

fibrocartilage formation

Functional ankylosis

Bone regeneration

Sequence of bone
regeneration
-

Immediate (Inflammatory)
response Bone formation Bone remodaling

Bone regeneration

Bone regeneration

Blood clot holds a pool of

chemoattractive and mitogenic

growth factors
-

PDGF

TGF-
VEGF

Blood clot provides a temporary

extracellular matrix on which

cells can grow

Bone regeneration

Bone regeneration
Bone marrows

Surrounding Soft tissue

Mesenchymal progenitor cells

Circulation

Periosteum

Bone regeneration

Anatomical fundamentals

Haematoma Vessel- and collagen formation Mineralisation of collagen Bone maturation Remodelling
REM: Aggregation auf der Kollagenmatrix

De novo bone formation on implant surfaces

bone sialoprotein osteocalcin activated by Cbfa1 osteopontin Cbfa1 osteopontin osteoblast lining cells collagen alcal. phosphatase osteopontin

new formed bone

osteocyte
cement layer

implant

1. 2.

early osteopontin expression at initial cement layer formation collagen matrix on the cement layer is mineralised by alc. phosph. and BSP

3.
4.

osteocalcin and osteopontin expression at initial mineralisation

osteopontin essential part of the organic bone matrix beneath the lining cells and surrounding the osteocyt lacunas
Sodek,J. und Cheifetz,S.: Molecular Regulation of Osteogenesis, aus Bone Engineering; em squared incorporated, Toronto, Canada;37 (1999 )

Healing of endosseus implants

Osteoconduction
Migration of osteogentic cells to the implant surface De novo bone formation - contact osteogenesis Remodelling

Prerequisites for osteointegration

1. Precise fitting

(design and inserting techniques)

2. Primary stability 3. Adequate loading (Biomechanics) 4. Bioinert / bioactive materials 5. Proper surface configuration

Precise fitting

Shape Surface Retention form

Cortical bone osteointegration

Maximum direct bone-implant contact Press-fitting phenomenon Cause local overload Overload -> microcrack, fissure Bone becomes avascular and necrotic in early stage In second stage - bore hole replace by lamella bone in 3 months In 15 months - 60-70% living bone contact

Cancellous bone osteointegration

Provide less primary stability Only 20-25% density compare to compact bone Vascular rich / osteoblast rich Divided into two area 1. Trabeculae contact 2. Marrow contact

Stages of implant surgery

1. Two stages surgery 2. One stage surgery

3. Immediate function

Non-Submerged Method (One-stage implant)

Submerged Method (Two-stage implant)

Possibilities of loading
Immediate implantation + immediate loading Immediate implantation + shortened healing phase

Immediate implantation + standard healing delayed implantation + shortened healing phase

delayed implantation + standard healing phase

Alveolus healing periimplant bone healing

functional loading

* Schliephake; Konzepte zur Verkrzung der Behandlungsdauer. Implantologie; 9/4: 357-372 (2001)

implant retention

biological

immediate-, rsp. early loading

mechanical

1. Two stages surgery

Widely acceptable procedure
stage I : Implant fixture placement stage II : Soft tissue exposure for abutment

placement period between both

stage depends on bone quality

Bone

Higher failure rate is sometimes encountered in type I and II bone

Overheat Optiomal drill spead / irrigation / pretapping

Implant site preparation

If the temperature of the bone exceeds 47 C for 1 minute, bone resorption and fat cell degeneration occurs
Eriksson and Albrektsson 1983

Dense bone

: 1500 rpm
Misch 1993

Cancellous bone : 800 rpm

Bone tapping

Recommended for cases in which the bone is dense, compact and poorly vascularized (Type I or II) Not recommended for type III or IV

Overpreparation Fibrous encapsulation

Implant site preparation

Overheating the bone is due to 3 factors

-

Using dull drill

Inadequate irrigation
Torquing or drilling at high speed
Collins and Collins 1998

Implant insertion

Principle
-

Primary stability is required No excessive force For screw-implant : 10-20 rpm 20-50 Ncm

Selection length of the fixture

Anatomical limitation :
1. Inferior alveolar nerve 2. Maxillary sinus 3. Bone mass

Anchorage needed

Tip size by drill diameter

Drill Tip

H L= -c-s M
15 L= 22=8 5/4

Prediction for proper direction of fixture : There are many way to determine
1. Surgical stent

2. Guide pin
3. Occlusion 4. Teeth adjacent to the space 5. Intraop. X-Ray

Importance of correct direction

Correct prosthetic-implant
angulation

Correct loading transfer

Correct intercoronal distance Correct path of prosthetic insertion

Stage II procedure

Keep keratinized tissue as

important point

Create interdental papillae when possible - in esthetic area

Abutment selection

Bone

Long-term success of dental implants appears to be highly dependent on both quality and quantity of the available bone
Jaffin Ra, Berman CL 1991

Jaw shape and bone quality must be regarded as the most influential factors affecting implant survival
Friberg et al 1991

Edentulous mandible and maxilla

Classification
1 2 3

Bone Quanlity
The entire mandible/maxilla is composed of homogeneous compact bone. A thick layer of compact bone surrounds a core of dense trabecular bone. A thin layer of cortical bone surrounds a core of low-density trabecular bone of favorable

strength.
4 A thin layer of cortical bone surrounds a core of low-density trabecular bone.

Lekholm U, Zarb GA 1985

Edentulous mandible and maxilla

Classification
A B C D E

Bone Quantity
Most of the alveolar ridge is present. Moderate ridge resorption has occured. Advanced alveolar ridge resorption has occurred, and only nasal bone remains. Some resorption of the basal bone has taken place. Extreme resorption of the basal bone has taken place.
Lekholm U, Zarb GA 1985

Surgery department Dental faculty Mahidol University

Maxilla vs. Mandible

Maxilla
-

Healthy

: Type II-III, Jaw shape A-C

Resorbed : Type III-IV, Jaw shape D-E Limitation : Maxillary sinus

Madible
-

Healthy

: Type I-II, Jaw shape A-C

Resorbed : Type I-III, Jaw shape D-E

Limitation : Mandibular canal

Bone morphology for implant placement planning

Bone resorption
Change of angle class Change of intermaxillary distance

physiological tooth axis

implant axis at labial bone resorption

Defect
Bone?

Soft tissue?

Several surgical techniques available for correction of atrophic ridge

Guided bone regeneration Bone condensing, spreading, splitting Autogenous bone graft Bone substitute Sinus lift Nerve transpositioning Interpositional bone graft Microvascular free flap

Guided tissue regeneration

Osteopromotion system Promote osseous healing in defect Exclude non-osteogenic soft tissue from defect healing

Guided tissue regeneration

As soft tissue support and prevention for collapse of space Creation of clot space provide osteogenic cells migration Protection of granulation tissue Promote vascular network formation

Ideal position for GTR

Collapse

Bone condensing

Principle
-

Nonablative implant bed preparation Condensation of spongiosa at boneimplant contact Alveolar ridge extension horizontally and vertically To improve primary stability in D3, D4 bone density Thin alveolar ridge (>3 mm) Closed sinus lift

Indication
-

Bone condensing

Procedures
-

Incision Initial preparaton

Lindemann-bur

Apply bone condenser instrument Preparation of implant bed

Bone spreading

Principle
-

Nonablative implant bed preparation as well as alveolar ridge extension Condensation of spongiosa at boneimplant contact Thin alveolar ridge (at least 3 mm) Bone density D3 and D4

Indication
-

Bone spreading

Instruments
-

Standard surgical set Standard implant set Bone condenser set

Osteotome set (Steri Os)

Bone condenser (Dentsply Friadent) Summers Osteotome set (Implant Innovations)

Dilatatoren set (Osteo Ti)

Bone spreading

Precedures
-

Incision & Flap preparation

Parapapilla incision

Crestal incision
Fine Lindemann-bur, Disc

Cortical osteotomy

A width of 2-4 mm

Pilot drill at center of alveolar ridge

Lindemann-bur

Bone spreading

Procedures
-

Apply bone condenser instruments

Use the instrument step-by-step Apply through pilot hole until the expected depth Rotation and anteroposterior extension

Stop the manuveurs if the alveolar ridge width is adequate for implant placement
Last implant preparation bur

Preparation of implant bed

Segmental bone splitting

Principle
-

Pre / Intraimplantation osteotomy of alveolar ridge bucco-lingually Mobilisation of segments in transverse direction Atrophic alveolar ridge width (2 mm) Adequate bone height

Indication
-

Segmental bone splitting

Instruments and materials

-

Standard surgical set

Standard implant set

Diamond disc
Chisels Bone condenser set Bone substitues (if need)

Segmental bone splitting

Procedures
-

Incision and flap preparation Osteotomy of cortical bone

Diamond disc Distance from neighbouring teeth ~ 1 mm Osteotomy at midcrestal bone and mesial/distal

Splitting the alveolar ridge

Chisels Green-stick fracture Stability mostly from lingual side

Preparation of implant bed

Segmental bone splitting

Procedures
-

Fixation of segment (with plate and screws)

Periimplant / Interlamellar bone augmentation

Autogenous bone Bone substitues

Bone augmentation

3 mm. 5 mm.

Bone graft

Autogenous bone graft are considered to be the gold standard Advantages

No risk of immunological rejection No risk of disease transmission

Osteoinductive and osteoconductive potential

Source of osteoprogenitor cells

Burchardt 1983,Hirsch and Ericsson 1991,Lundgren et al 1996, Raghoebar et al 1993,Wood and Moore 1988

Autogenous bone graft

Disadvantages

Limited amount of graft available in intraoral donor sites

The need for a general anesthesia and

hospitalization in extraoral donor sites Additional surgical sites Donor site morbidity
Laurie et al 1984,Nkenke et al 2001,Nkenke et al 2002, Nkenke et al 2004,Younger and Chapman 1989

Bone graft

Using bone substitutes avoids or reduces problems associated with autogenous bone graft harvesting

Ideal grafting characteristics

The ability to produce bone by cellular proliferation from viable transplanted osteoblasts or by osteoconduction of cells along the grafts surface The ability to produce bone by osteoinduction of recruited mesenchymal cells Remodeling of the initially formed bone into mature lamellar bone Maintainance of the mature bone over time without loss through function The ability to stabilize implants when placed simultaneously with the graft Low infection rate Ease of availability Low antigenicity High level of reliability

Bone graft

Sinus lift in 94 Pt., 362 Implants 9 types of bone grafting materials

-

Autogenous bone DFDBA (Lifenet) Calcium carbonate (Biocoral) Bioactive glass (Bioglass) Polymer of polylactic & polyglycolic acids (Fisiograft) Bovine-derived bone and peptide (Pepgen P-15) Calcium sulfate (Surgiplaster sinus) Bovine deproteinized bone (Bio-Oss) Hydroxyapatite (Fingranule)
Scarano et al 2006

Bone graft

Scarano et al 2006

100 %

New bone

Bone substitue Auto.bone t

Maxillary sinus

Maxillary sinus is a pyramidshaped cavity with its base adjacent to the nasal wall and apex pointing to the Zygoma Adult sinus

2.5 3.5 cm. wide 3.6 4.5 cm. tall 3.8 4.5 cm. deep Volume 12-15 cm3

Van den Bergh et al 2000

History

Maxillary sinus graft was first described by Tatum at Alabama implant conference in 1976
First published by Boyne & James in 1980 Osteotome technique was described by Summers in 1994

Sinus lift

Principle
- Elevation of Schneiderian membrane to recontour the sinus in the cranial direction and followed by bone graft

Indication
-

Insufficient alveolar height of post. maxilla

Optimal interarch space

Sinus lift

Procedures
-

Incision and flap preparation Osteotomy to perform a bone window

Round diamond bur Preventing tear of sinus membrane

Elevation of Schneiderian membrane If residual ridge 4 mm : Simultaneous implantation is possible

Misch 1987, Watzek 1996, Ulm et al 1995

Bone augmentation

Sinuslift Consensus Conference,

Nov.96, Babson College, Ma, USA, special supplement JOMI, Vol.13, 1998 1107 Sinus augmentationen
2997 Implantation 229 Implants loss

5-year survival rate of implants

84.5 %
Simultaneos implantation

93.1 %
2-Stage implantation

20

40

60

80

100

Sinuslift Consensus Conference, Nov.1996, Babson College, Ma, USA

Sinus lift & Implant survival rate

Author Year Number of Patients
50 16 150 216 23 47 13 29 63 21 20 52 99 39 42

Number of sinus lifts

97 27 167 216 39 47 ? 45 63 24 20 98 182 75 60

Number of Implants
201 73 167 467 67 181 ? 120 160 57 55 204 392 207 161

Implantation
sec sim sec sim sim/ sec sim sec sim/ sec sim sim sim

F/U

Implant Survival rate

Blomqvist Block Fugazzotto Khoury Kbler Lekholm Lorenzetti Olson Peleg (a) Peleg (b) Peleg Raghoebar Raghoebar Smedberg v. d. Bergh

1998 1998 2002 1999 1999 1999 1998 2000

50 72 36 49 24-48 36 ? 38,2 24-48 8-10 26,4

84,2% 95,9% 97,8% 94,0% 94,1% 76,0% ? 97,5% 100,0% 100,0% 100,0% 93,3% 91,8% 100,0% 100,0% 79,0% 89,0% 95,4% 95,0% 95%-100%

1999
1999 1998 1999 2001 2001 1998 2000 2000 1998 1999 1998

sec
sec sim ? sim sec sec sim sim/ sec

32
12-124 36 12-72 12 12 70 24 30

Wannfors
Wannfors Watzek Wiltfang Zitzmann

20
20 7 53 30

?
? 14 63 30

76
74 53 132 79

Total

994

1240

2853

sim: 1629 sec: 1224

93,59 %

Nerve transpositioning

Principle
-

Transposition of inferior alveolar nerve to achieve primary stability without bone augmentation Inadequate alveolar height of posterior mandible Optimal interarch space Compression of mental nerve

Indication
-

Distraction osteogenesis

Principle
-

Controlled, gradual vital bone regeneration between osteotmy segments Increase alveolar ridge height without bone graft Vertical alveolar atrophy Adequate bone width Open bite

Indication
-

Microvascular free flap

Local or regional tissues are unavailable or inadequate

Application of locoregional tissues would result in

significant or esthetic loss When bone reconstruction is required Pt. must withstand a long operative procedures

Post-surgical interim prosthesis management

Relieve acrylic in area of implant

Reline with tissue conditioner Avoid loading by all means Avoid wearing in 1st-2nd weeks

Soft diet
Daily gentle cleansing

Soft tissue management

Flap design Modified palatal roll technique Free gingival graft

Connective tissue graft

Vascularized interpositional periosteal-

connective tissue (VIP-CT) flap

Papilla regeneration

Membrane

Flap design
Principle

Preserve blood supply Preserve the topographic of alveolar ridge and mucobuccal fold Identification of important anatomic structures Provide access for implant instrumentation and use of surgical guides Provide access for harvesting of local bone Provide for closure away from implant or tissue augmentation sites Minimize bacterial contamination Facilitate circumferential closure around permucosal implant structures

Flap design

Buccal (Facial) flap

a: - submerged implant b: - nonsubmerged implant - abutment connection

Papilla reflection

Indication
-

Immediate implant placement No need of augmentation

Parapapilla incision

Indication
-

Immediate / Delayed implantation Limited defect only coronally

Parapapilla incision with vestibular extension

Indication
-

Immediate / Delayed implantation Alveolar ridge defect

U-shaped peninsula flap

Indication
-

Esthetic implant site Access of the buccal aspect is unnecessary No need of augmentation To prevent scarring and soft tisssue recession

U-shaped peninsula flap

(Mid)crestal incision

Curvilinear incision

Indication
- As trapezoidal flap

Advantages
-

Incorporation with a greater volume of mucosal tissue Improving elasticity Flexible for flap adaptation or transposition Good esthetic results Allow for correction of hard and soft tissue defects simultaneous with implatation Cutback incision reduces the need of periosteal releasing incision

Curvilinear incision

Modified palatal roll technique

Modified palatal roll technique

Free gingival graft

Connective tissue graft

Skin graft

VIP-CT flap

Papilla regeneration

Membrane

1 week

2 weeks

THANK YOU VERY MUCH FOR YOUR ATTENTION