10º Simpósio Ibérico Biomet3i - Jan. 2011

Minimally invasive surgical procedures
Clinical Guidelines for a Successful Outcome

Gonçalo Seguro Dias
Oral Surgery and Oral Pathology Dept
School of Dentistry, Lisbon University
quarta-feira, 26 de Janeiro de 2011

Gonçalo
Seguro Dias

Aknowledgments:
Ana Luísa Silva
Teresa Casaca
Vanessa Osório

For a handout of this lecture please contact by email:

goncalosegurodias@gsd-dentalclinics.com


 Less trauma for
the patient than
an equivalent
invasive procedure.

Definition


 More or less expensive;

 Operative time not essential;

Definition  Less pain and less posoperative complications;

 Faster recovery.


Treatment
plan trends


Patient’s Perspective
 Less surgical steps;
 Short treatment time;
 Maximize comfort;
 High success rate;
 High esthetic and functional
outcome.


Patient’s Perspective Clinician’s Perspective

 Less surgical steps;  Less surgical steps;
 Short treatment time;  Less chair time;
 Maximize comfort;  High success rate.
 High success rate;
 High esthetic and functional
outcome.

t’s
ien e
Pat tiv
rspec
Pe
Clinici
an’s
Perspe
ctive


Biologic and clinical rational for a successful outcome
regarding minimally invasive surgery in treatment plan.

Bone/soft
No bone/soft
Topics tissue
Immediate
implants
tissue
discrepancies
discrepancies
*
* ASSUMPTION:
all implants in
esthetic anterior
areas
need bone/soft
tissue grafts

No bone/soft Bone/soft
Topics tissue
Immediate
implants
tissue
discrepancies discrepancies


Brodala N. Flapless surgery and its effect on dental implant outcomes. Int J Oral
Maxillofac Implants. 2009;24 Suppl:118-25.

Becker W, Goldstein M, Becker BE, Sennerby L, Kois D, Hujoel P. Minimally
invasive flapless implant placement: follow-up results from a multicenter study. J
Periodontol. 2009 Feb;80(2):347-52.

Papaspyridakos P, Lal K. Immediate loading of the maxilla with prefabricated
interim prosthesis using interactive planning software, and CAD/CAM
rehabilitation with definitive zirconia prosthesis: 2-year clinical follow-up. J
Esthet Restor Dent. 2010 Aug;22(4):223-32.

Rousseau P. Flapless and traditional dental implant surgery: an open,
retrospective comparative study. Oral Maxillofac Surg. 2010 Sep;68(9):2299-306.


Full Arch Rehabilitation


Single Unit Rehabilitation


Treatment Plan Options

Removal of the Try to remove
implant and the broken screw
replacement with
another implant


Considerations

Screw not loose;
Only active part of screw is inside the implant;
Anxious patient.


Changes in implant primary and
secondary stability over time


Guided ADVANTAGES
Surgery/ Reduced treatment time;
Mini flaps Reduced morbility.


CB CT planning
Guided
Surgery/
Mini flaps


CB CT planning
Guided
WHEN?
Surgery/
Mini flaps Nodoubts regarding the
bone or soft tissue volume.


 Caneva M, Botticelli D, Salata LA, Souza SL, Bressan E, Lang NP. Flap vs. "flapless" surgical approach at immediate


implants: a histomorphometric study in dogs. Clin Oral Implants Res. 2010 Dec;21(12):1314-9.
Caneva M, Botticelli D, Salata LA, Scombatti Souza SL, Carvalho Cardoso L, Lang NP. Collagen membranes at
Immediate
immediate implants: a histomorphometric study in dogs. Clin Oral Implants Res. 2010 Sep;21(9):891-7. implants
 Caneva M, Salata LA, de Souza SS, Bressan E, Botticelli D, Lang NP. Hard tissue formation adjacent to implants of
various size and configuration immediately placed into extraction sockets: an experimental study in dogs. Clin Oral
Implants Res. 2010 Sep;21(9):885-90.
 Caneva M, Salata LA, de Souza SS, Baffone G, Lang NP, Botticelli D. Influence of implant positioning in
extraction sockets on osseointegration: histomorphometric analyses in dogs. Clin Oral Implants Res. 2010 Jan;21(1):
43-9.
 de Sanctis M, Vignoletti F, Discepoli N, Zucchelli G, Sanz M. Immediate implants at fresh extraction sockets: bone
healing in four different implant systems. J Clin Periodontol. 2009 Aug;36(8):705-11.
 Ferrus J, Cecchinato D, Pjetursson EB, Lang NP, Sanz M, Lindhe J. Factors influencing ridge alterations following
immediate implant placement into extraction sockets. Clin Oral Implants Res. 2010 Jan;21(1):22-9.
 Tomasi C, Sanz M, Cecchinato D, Pjetursson B, Ferrus J, Lang NP, Lindhe J. Bone dimensional variations at
implants placed in fresh extraction sockets: a multilevel multivariate analysis. Clin Oral Implants Res. 2010 Jan;21
(1):30-6.
 Vignoletti F, Johansson C, Albrektsson T, De Sanctis M, San Roman F, Sanz M. Early healing of implants placed
into fresh extraction sockets: an experimental study in the beagle dog. De novo bone formation. J Clin Periodontol.
2009 Mar;36(3):265-77.


Implant Location (vertical dimension)
 Botticelli, 2004; Covani, 2007; Buser, 2008; Caneva, 2010 Immediate
Implants
Buccal plate thickness Assessment
 Araújo, 2004; Botticelli, 2004; Araújo, 2005; Botticceli, 2006; Nevins, 2006;
Chen, 2007; Ferrus, 2010; Huynh-Ba, 2010; Tomasi, 2010

No flap procedures
 Blanco, 2008, 2010; Sainz, 2010

Horizontal void
 Araújo, 2005; Ferrus, 2009; Sanz, 2009; Huynh-Ba, 2010; Tomasi, 2010

Immediate provisionalization
 Wohrle 1998; Kan 2000; Hui 2001; Saadoun 2002; Covani 2004; Cornelini 2005;
Tortamano 2010; Valentini 2010


Upper Pre Molar Area


Upper Molar Area

 Acocella A, Bertolai R, Sacco R. Modified insertion technique for immediate implant placement into fresh extraction socket in the
first maxillary molar sites: a 3-year prospective study. Implant Dent. 2010 Jun;19(3):220-8.

 Bersani E, Coppede AR, de Paula Pinto Prata HH. Immediate loading of implants placed in fresh extraction sockets in the molar area
with flapless and graftless procedures: a case series. Int J Periodontics Restorative Dent. 2010 Jun;30(3):291-9.


Upper Molar Area


Lower Molar Area


Patient Considerations
 Case selection is critical for sucess:
- Healing problems; thick biotypes; smokers,...

Surgeon
 Atraumatic extraction (root separation mandatory);
 Implant placement in an ideal 3d restorative position;
 Familiar with GBR procedures.

 Skillfull - know what to do when things go wrong!


Bone/soft
No bone/soft
Topics tissue
Immediate
implants
tissue
discrepancies
discrepancies
*
* ASSUMPTION:
all implants in
esthetic anterior
areas
need bone/soft
tissue grafts

No bone reconstruction required
Extraction
Implant placement
Timing for Abutment connection
SOFT
Soft TISSUES
Tissues MANAGEMENT

Management Bone reconstruction required

Extraction
Abutment connection


Lateral Incisor


Lateral Incisor

Considerations
Periodontal afected tooth;

Vertical bone deficiency;

Soft tissue deficiency.


Lateral Incisor

8 weeks after


Lateral Incisor

Buser 2005


GBR procedures; Hard Tissue
Bone blocks;
Discrepancies
Short/Tilted implants;
Alveolar distraction;
Zygomatic implants.


GBR procedures; Hard Tissue
Bone blocks;
Discrepancies
Short/Tilted implants;
Alveolar distraction;
Zygomatic implants.

How can we be minimally invasive?


Partial Edentulism



 Cyst removal and wait for healing

 “Cyst elevation”


Partial Edentulism

6 months after


Total Edentulism


 Bilateral sinus lift;
 Short implants;
 Tilted implants.


das Neves FD, Fones D, Bernardes SR, do Prado CJ, Neto AJ. Short implants--an
analysis of longitudinal studies. Int J Oral Maxillofac Implants. 2006 Jan-Feb;21(1):
86-93.
Short
Grusovin MG, Coulthard P, Worthington HV, George P, Esposito M. Interventions for
replacing missing teeth: maintaining and recovering soft tissue health around dental
Implants
implants. Cochrane Database Syst Rev. 2010 Aug 4;(8):
Misch CE. Short dental implants: a literature review and rationale for use. Dent Today.
2005 Aug;24(8):64-6, 68.
Morand M, Irinakis T. The challenge of implant therapy in the posterior maxilla:
providing a rationale for the use of short implants. J Oral Implantol. 2007;33(5):
257-66.
Raviv E, Turcotte A, Harel-Raviv M.Short dental implants in reduced alveolar bone
height.Quintessence Int. 2010 Jul-Aug;41(7):575-9.
Romeo E, Bivio A, Mosca D, Scanferla M, Ghisolfi M, Storelli S.The use of short dental
implants in clinical practice: literature review.Minerva Stomatol. 2010 Jan-Feb;59(1-2):
23-31.


Severe Atrophic Maxilla


Bone reconstruction with autologous and xenograft (no
Treatment
immediate load; 8-12 months treatment lenght; no Plan Options
provisional).


Treatment
Plan Options

Bilateral sinus lift (no immediate load; 6-8 months
lenght).


Treatment
Plan Options

Zigomatic implants (immediate loading; shorter treatment
time; less morbility).


Davo R.Zygomatic implants placed with a two-stage procedure: a 5-year Surgical
retrospective study.Eur J Oral Implantol. 2009 Summer;2(2):115-24. Alternatives
Esposito M, Worthington HV, Thomsen P, Coulthard P.Interventions for
- Zygomatics
replacing missing teeth: dental implants in zygomatic bone for the rehabilitation
of the severely deficient edentulous maxilla.Cochrane Database Syst Rev. 2003;
(3).

Kuabara MR, Ferreira EJ, Gulinelli JL, Paz LG.Rehabilitation with zygomatic
implants: a treatment option for the atrophic edentulous maxilla--9-year follow-
up.Quintessence Int. 2010 Jan;41(1):9-12.

Malevez C, Daelemans P, Adriaenssens P, Durdu F.Use of zygomatic implants to
deal with resorbed posterior maxillae.Periodontol 2000. 2003;33:82-9.


Take home messages


Treatment Plan Decision Making for No Bone/ Soft Tissue Discrepancies Cases

No bone/soft CBCT evaluation Guided
Surgery / Predictable
tissue Outcome
discrepancies Miniflap


Treatment Plan Decision Making for Immediate Implants

2nd
No GBR surgery Predictable
preservation or for Outcome*
GTR implant
placement

Implant Placement
Abort

Immediate Tooth Buccal Implant
Extraction Plate Primary placement Predictable
Implants with/
Stability Outcome
without
GBR
How skillful are you?

Preservation

2nd
No Primary GBR surgery Predictable
Stability or for
GTR implant Outcome
placement
Implant Placement
Abort

Treatment Plan Decision Making for Bone/ Soft Tissue Discrepancies Cases

Extreme bone ZYGOMATIC
resorption IMPLANTS

Specific Vertical Defects ALVEOLAR
DISTRACTION
Patient sensitive

Bone/Soft Soft GBR/ Implant Predictable
Bone Specific Locations
Tissue Tissue Regeneration SINUS placement Outcome
Discrepancies Regeneration LIFT

BONE
Specific Locations BLOCKS
Case sensitive

SHORT/
Posterior Areas TILTED
Anterior bone height of IMPLANTS
10mm and width 5 mmm


Custom made
treatment plans
regarding both
patient
evaluation and
clinician skills.


Do not start
your treatment
plan if you do
not know what
to do if things
go wrong.


NO evidence to
suggest that
simultaneous site
development and
implant loading is
predictable.


You choose your success rate!


Thank you very much
for your attention!

goncalosegurodias@gsd-dentalclinics.com


10º Simpósio Ibérico Biomet3i - Jan. 2011

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