Immediate implants/ esthetic in dentistry

GOOD MORNING
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Delayed implantsImmediate implants VS CONVENTIONAL
IMPLANTS
INDIAN DENTAL ACADEMY
Leader in continuing dental education
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MOST EDENTULOUS SITES
ARE ATROPIC
RESULT OF
INADEQUATE
MECHANICAL
LOADING
PLACING AN IMPLANT
OVERRIDES
THE ATROPIC
ELICITS
TIME DEPENDENT , LOCALIZED
HEALING RESPONSE
CONTROLLED
BY
CYTOKINES
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Immediate implant placement
Placements of implants into fresh extraction sites
Offers a no. of advantage to
Both the patients & the clinicians
With out the support provided by functioning dental units, the bony
receptor sites soon undergone a
catabolic phaseVarying amounts of atrophy after tooth removal
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Recession of the mucosal & gingival tissues accompanies & follow
changes in the alveolar ridge
achievement of
Superior aesthetic is more difficult in particularly in
Aesthetic zone of anterior maxilla
RESULTING IN
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implants in extraction sites can be placed in the same position
As the extracted teeth
Facilitates final restoration & minimizes need for severely angled
Abutments /fabrication of telescopic copings
Surgeon can position the implant more favorably than the
original position
socket as a Guide for determination of parallelism & alignment
to the opposing & adjacent teeth
Reduces the treatment time & interval during the
transitional period
Patients acceptability
Advantages regarding immediate implants
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Treatment sequence & planning protocol
Clinical
Examination
Radiographic
examination Fabrication of
Surgical
Guide Surgical &
Prosthetic
phase
Maintenance
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Radiographic examination
The radiographic examination indispensable for
Determining the volume & density of the bone
Bone volume
Available bone volume Necessary bone volume
Computerized
tomography
Scanora
Surgical
Evaluation
Ex; single molar replacement
M.D X W.O.C X I.L
8 mm X 8mm X 10mm
Useful bone
Volume
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Available bone volume Necessary bone volume
Useful bone
Volume
Surgical evaluation Prosthetic evaluation Surgical
+
Prosthetic
Evaluation
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Bone density
Good evaluation of bone density allows the surgeon to do the following
Select the Proper
implant diameter
Decide about the
optimal drilling
Determine the length of
Healing period
Evaluate the occlusal load capacity
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Classification of bone quality
Mechanical aspect
( bone density )
LEKHOLM&
ZARB
(1985)
Healing Stand Point
( bone biology )
Type I –Essentially cortical bone
Type II –dense corticocancellous bone
Type III –Sparse corticocancellous bone
Type IV – thin cortical & very sparse
medullary bone .
BHP 1-normal healing
potential.
BHP 2—Moderately
reduced healing
potential.
BHP 3—substantially
Reduced healing
potential.
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Surgical guide
Serves link between prosthetic & surgical teams
Guide may be designed in several different manner
Impression
Fabrication of ideal surgical guide
Without consideration of anatomic conditions
Surgeons judges the best surgical possibilities
Suited for large volume & for the
Posterior teeth
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Impression
Fabrication of the radiographic guide with
Positioning of the radiographic markers
( judgment of the prosthetic limitations )
Scanner procedure
( bone volume )
Modification of the radiographic guide
into precise surgical Guide
Surgeon follows the exact indications of the guide
Preferred for solutions with high esthetic demands
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Treatment sequence
Selected based on the following parameters
Patient’s
Health condition
Keratinized mucosa
Bone density
No. & relative
position of the
Implants Plaque
control
Stability
Of the
transitional
Prosthesis
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Treatment sequence
Standard Protocol
(Option 1)
One -stage surgery
(Option 2)
Option 1 +With the impression
At stage 1surgery
(Option 3)
One -stage surgery+
With the impression
At stage 1surgery
Option 4
Immediate loading
(Option 5 )
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Standard Protocol
(Option 1)
Stage 1 surgery ( implant insertion )
Healing phase ( 3 to 6 months )
+ provisionalization
Stage 2 surgery
( placement of healing abutment )
Final abutment placement
Impression for the final prosthesis
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One -stage surgery
(Option 2)
Stage 1 surgery ( implant insertion )+
placement of the healing abutment
Final abutment placement
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Standard protocol + With the impression
At stage 1surgery
(Option 3)
Stage 1 surgery ( implant insertion +
impression )
stage 2 surgery +Final abutment placement
+ provisional acrylic resin prosthesis
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Stage 1 surgery implant insertion +
impression
placement of the healing abutment
Final abutment placement +
provisional acrylic resin prosthesis
One -stage surgery With the impression
At stage 1surgery
(Option 4)
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Immediate loading
Option 5
Stage 1 surgery +
placement of final abutments
Gingival healing
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Protocols for implant placement in extraction sockets
Type 1
Implant placement immediately following tooth extraction
&as a part of the same surgical procedure
Advantages Disadvantages
Reduced no. of surgical procedure &
over all treatment time
Optimal availability of existing bone
Site morphology
Thin tissue biotype
Lack of keratinized mucosa
Technique sensitivitywww.indiandentalacademy.co
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Type II
COMPLETE SOFT TISSUE COVERAGE OF THE SOCKET
TYPICALLY 4 –8 WEEKS
Advantages
Increased soft tissue area
& volume
Resolution of local pathology
Disadvantage
Varying amounts of resorption
increased Treatment time
Adjunctive surgical procedures
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Type III
SUBSTANIAL CLINICAL /RADIOGRAPHIC BONE FILL OF THE SOCKETS
TYPICALLY 12 –16 WEEEKS
ADVANTAGES
Bone Fill facilitates
implant placement
Flap management
Disadvantage
Same as type II
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TYPE IV
HEALED SITE(TYPICALLY >16 WEEEKS)
ADVANTAGES
CLINICAL HEALED RIDGE
FLAP MANAGEMENT
DISADVANTAGE
SAME AS TYPE II
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KEY ASPECTS OF THIS CLASSIFICATION
IN clinical practice the decision to place an implant following
Tooth extraction is usually
Determined by
The attainment of specific soft & hard tissue characteristics of the
healing socket
These events do not necessarily follow rigid time frames &may
vary according to the site & patients factors
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To avoid time based descriptions , this classification uses
numeric descriptors
Type I –IV THAT REFLECT the soft & hard tissue changes
observed
Clearly separates healing of the soft & hard tissues
Type I is chosen when an implant is placed immediately following
extraction
Type II IS when advanced soft tissue healing is desired
preferred
Type IV hard tissues healing is desired
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HISTOLOGY & CLINICAL TRIALS
MOST REPORTS ON IMMEDIATE IMPLANT PLACEMENT DESCRIBES
Small peri implant osseous defects result in a gap measurable
From the wall of the socket to the surface of the implant
Defect as
Horizontal defect dimension (HDD)/jumping distance
HDD IS 2mm /less
in width
No augmentation /membrane required
Spontaneous bone healing
&
Osseointegration will occur
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Healing of immediate& delayed implant sites
The majority of studies reported that peri implant defects associated
with immediate implants healed with significant bone fill , irrespective
of the placement protocol & augmentation methods used .
However ,significantly better bone fill & less crestal bone resorption
were reported at immediate implant sites treated with demineralized
Freeze dried bone combined with non resorabable barrier membranes
Versus sites treated with non resorbable barrier membrane alone .
Most of the studies reported that better DEFECT HEIGHT (DH) &
DEFECT AREA (DA) REDUCTION at delayed sites compared to
immediate sites .
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Sockets with dehiscence defect may
Lack the potential for complete regeneration,
risk of complications may be increased with
immediate implants sites
In a comparative study , significantly greater height reduction was
achieved in dehisced sites with delayed compared to immediate
placement
Interestingly , early placement showed consistently better reduction of
dehisced defects than did late implantation in healed ridges
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Bone integration of immediate & delayedBone integration of immediate & delayed
implantsimplants
• Basics prerequisites for successful bone healing in immediate &
delayed implant sites are the same as for the implant placed in healed
ridges .
• In addition ,a space often exists bet surface of the implant &
wall of the socket need to be filled with bone to achieve
optimal outcome .
• This bone healing is dependent on stabilization of the initially
formed coagulum in this space .
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In the intact socket , a critical component of the peri implant defect is
the size of the horizontal defect (HD ) .
Implants With a HD of 2mm / less spontaneous healing
&
osseo integration takes
place , if the
implant has rough surface
HD in excess of 2 mm to achieve bone healing bone fill
like by using collagen barrier
membrane & implants with a sand
blasted &acid etched surface
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Indications
Replacing teeth with
Immediate implants
Retained deciduous teeth Vertically & horizontally
Fractured teeth
Tooth lost due to nonrestorable dental caries ,
periodontal disease ,
endodontic failure
Poor esthetics
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Main advantage of immediate implant placement
Timing of implant placement following tooth removal may be
important to take advantage of soft tissue healing
But without risk of losing bone volume through resorption .
The data to support enhanced soft tissue esthetic outcomes
with delayed implant placement are lacking
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Certain clinical factors to be considered ,
when assessing the applicability of
immediate restoration
Primary stability of the implant(s)
Adequate implant splinting where appropriate
Provisional restorations that promote splinting & reduce
/control the mechanical load applied to the implant
Prevention of provisional restoration removal
During the recommended period of implant
Healing
Incorporation of team approaches & the use
surgical templates
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Risk factors forRisk factors for
immediate implant placementimmediate implant placement
• Poor bone quality/volume
• Presence of infection
• Presence of high masticatory / para
functional habits
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CONVENTIONAL LOADING
THE PROSTHESES IS ATTACHED IN A SECOND
PROCEDURE AFTER A HEALING PERIOD OF 3 TO 6 MONTHS
EARLY LOADING
A RESTORATION IN CONTACT WITH THE OPPOSSING
DENTITION & PLACED ATLEAST 48HRS AFTER IMPLANT
PLACEMENT BUT NOT LATER THAN 3 MONTHS
AFTERWARDS
DELAYED LOADING
THE PROSTHESES IS ATTACHED IN A SECOND
PROCEDURE THAT TAKES PLACE SOME TIME LATER
THAN THE CONVENTIONAL HEALING PERIOD OF
3 TO 6 MONTHS
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Immediate restoration
A restoration inserted within 48 hrs of implant placement but not in
Occlusion with the opposing dentition
Immediate loading
A restoration placed in occlusion with the opposing dentition
within 48 hrs of implant placement .
Prosthetic connection in occlusion to an implant within 48 hrs of
Surgical implant placement
ITI CONSENSUS CONFERENCE
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Difference bet
Immediate functional loading Immediate non functional loading
Of implants involved patients
receiving prostheses with occlusal
function on the day of implant
placement
Provision of prostheses 1 to 2mm
Short of the occlusal contact
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Guidelines for extraction
When planning for immediate implant placement
Pre operative evaluation
Antibiotic therapy initiation
Preservation of the bony
Receptor sites
Procedural delays Interoperate decision
Avoidance of excessive pressure
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Osteotomy preparation
Improvements for primary stability
Bone grafts
1973 , BOYNE (GUIDE
LINES FOR BONE GRAFT)
Rapid
osteogenesis
Not elicit an
immunologic
Responses
Osteoinductive
provide for
Osteo conduction
Soft tissue closure
Successful osseointegration
Implant loadingwww.indiandentalacademy.co
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Immediate placement of implant at the
time of extraction
Following tooth extraction ,a variable amount of ridge collapse
Takes place because of bone resorption .
This bone loss can occur in either buccal –lingual /
Apicocoronal dimensions / both.
As much as 3 to 4 mm of bucco lingual & apico coronal
Bone resorption during 6 months following extraction
To avoid these problems a
Technique has been introduced involving
Simultaneous tooth extraction &
Immediate implant placement
This technique allows
bone & Soft tissue
Preservation
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A traumatic extraction
After clinical / radiographic evaluation---
hopeless tooth extracted
No of instrument have been developed
Such as
Periotome
To sever the periodontal
Ligament
Whenever possible, surgeon should avoid to reflect a flap
to preserve the integrity of vascular supply & periosteum
covering the bone
Will minimize the bone resorption
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Absence of acute non
contained infection
Immediate
Implant placement
Determined by 3 factors
Achievement of initial
stability of the implant
Sufficient quantity &
quality of
Bone
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Presence of disseminated infection in an extraction socket
Delaying placement for about 3 weeks post extraction
May be considered to allow resolution of local pathology
& achievement of soft tissue closure .
Integrity of socket wall is evaluated
If the socket wall is intact
A favorable horizontal & vertical level of both
Soft tissue & bone architecture is present
Immediate implant placement may
be attempted
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The location of the implant in relation to the socket
appears to be critical determinant of the outcome of
regenerative treatment at dehisced sites .
Thus , implant should be placed well within the confines
of the socket to ensure a maximum no . Of bone walls &
to take advantage of the healing potential of the socket
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The three dimensional placement of the implant is
visualized & Planned
Using the surgical guide
It is often helpful to gauge the dimensions of the socket
Relative to implant configuration
By placing various depth gauges in the socket
For immediate implant placement ---
Engage at least 6 mm of bone of reasonable quality .
A minimum of 1mm of buccal plate should be maintained
To enhance long term prognosis & reduce the risk of
Soft tissue recession
Depth gauge
Help us to
Make that
assessment
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A concomitant soft tissue augmentation at the same time of
Implant placement may be recommended
In patients with a thin gingival biotype
To reduce the risk of soft tissue recession &
Buccal bone resorption
Followed by assessment of horizontal space
No bone augmentation bone augmentation
Grafting material
Include
( autogenous /allograft )
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Implant placement in edentulous sites
When an edentulous site in the esthetic zone is planned for
implant placement , the site must be thoroughly evaluated .
GARBER has proposed a classification for such sites .
This classification depends on the type of reconstruction
needed to get good positioning of the implant
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Garber class I
When favorable horizontal & vertical levels of both soft tissue
& bone are present
Implant placement is a straight
forward procedure
A concomitant soft tissue augmentation at the same time
of implant placement is preferred in patients with a thin
gingival biotype
To prevent the risk of
Soft tissue recession & buccal bone
Resorption
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Garber class II
Sites with no vertical bone loss & slight horizontal bone deficiency
Measuring about 1 –2mm narrower than normal can be expanded
By using serial osteotomes
instead of drilling , Describes by
Summers
Technique will permit
Slight expansion of bony ridge horizontally
While simultaneously compressing the maxillary
Bone to improve the bone quality
Always one alternative is to get sufficient initial stability of the
Implant & lateral augmentation of the ridge using bone grafting
Technique / bone regeneration technique
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Garber class III
FOR SITES WITH NO VERTICAL BONE LOSS & HORIZONTAL BONE
LOSS GREATER THAN CLASS II ,
Implant placement can be attempted ,
Provided an initial stability is achieved .
Guided bone regeneration is necessary
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Garber class IV
IN SITES WITH NO BONE LOSS BUT SIGNIFICANT
HORIZONTAL LOSS ,
IT’S necessary to staged approach
In which ridge is widened with guided bone regeneration
Implants are later placed after a suitable healing period of
several months using BLOCK BONE GRAFTS / GBR TECHNIQUE
AUTOGENOUS BONE GENERALLY BEEN THE GRAFT MATERIAL
OF CHOICE
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GARBER CLASS V
SITES WITH EXTENSIVE APICO CORONAL BONE LOSS PRESENT
A SIGNIFICANT CHALLENGE TO THE SURGEON
NON RESORABLE
MEMBRANE +
DELAYED IMPLANT
PLACEMENT
BARRIER MEMBRANE
WITH AN IMMEDIATELY ,
SUBMERGED IMPLANT AS
A SPACE MAKING UNDER
THE MEMBRANE
DISTRACTION
OSTEOGENESIS
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REGARDLESS OF THE OF PROCEDURE PLANNED FOR MATURE
SITE , PROPER FLAP MANAGEMENT IS GRIRTICAL FOR SUCCESS .
CAREFUL ATTENTION REGARDING
INCISION DESIGN
FLAP EXTENSION ----IN EFFORT TO PRESERVE THE BLOOD
SUPPLY
A PAPILLA SPARYING INCISION TO PRESERVE BLOOD SUPPLY
TO THE DELICATE INTER
DENTAL PAPILLA &
REDUCE
POST SUGICAL RECESSION
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Considerations in Esthetic Sites
Bone volume Position Abutment
interface
Emergency
profile
Appearance
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Ideal implant placement in
anterior maxilla
Esthetic implant placement is based on a ‘’Restorative driven
philosophy ‘’
Correct 3 dimensionally position of the implant is the driving
Force in implant placement .
Allow for optimal support & stability of the peri –implant
hard & soft tissues
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Recommended implant types in anterior maxilla
Standard screw , wide body , narrow neck , TE 4.1 / 4.8
& TE 3.3 / 4.8
To utilize these implants in ant . Maxilla , correct implant
selection relative to the mesiodistal dimensions of the tooth to
be replaced is critical
Gap size
When planning for an ideal 3
Dimensional implant position
Distinction made bet so
Called comfort & danger
Zones in each dimensions
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Comfort & danger zones are defined in mesiodistal , orofacial,
Apicocoronal dimensions
In mesiodistal dimensions Straumann implants systems
(implant body surface no closer than
1.5 mm to adjacent root surface)
Orofacial dimensions
Position of the implant shoulder margin
should be at the ideal point of
emergence
Implant shoulder is positioned about
1mm Palatal to the point of emergence at
adjacent Teeth
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Apicocoronal dimensions
Implant shoulder is positioned
about 1mm apical into CEJ of the
contra lateral tooth without
gingival recession
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Implant placement considerations
In posterior situations
Gingival scallop is relatively flat
Allows access for cement removal
& oral hygiene
Esthetic situations implant shoulder should be 2mm
below the mid facial gingival margin
ideal option should be screw retained
restorations
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Interim restorations during the healing period
Place a vacuform matrix with the denture teeth
Interim removable partial denture
Bonded restorations
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Abutment connections
All STRAUMANN abutments are seated & tighten up to 35Ncm
Should be performed with out local anesthesia .
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Restorative options / abutment selection
In straumann implant systems
Most commonly used abutment is
solid abutment
Primary abutment of
Choice in single posterior tooth .
& multiple tooth restorations.
Also in anterior regions
Only abutment for which an
impression is made directly
in the mouth
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Impressions / indexing of the implant may be performed
at any time .
The 2 part STRAUMANN implant has an
internal octagon / morse taper
synOCTA
synOCTA 1.5 mm abutment
Primary abutment of choice for esthetic screw retained
restorations
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Immediate restoration & loading of implants
in completely edentulous
Whether healing period of 3 to 6 months
Absolute prequisite for
Osseo integration
In particular , it should be demonstrated whether any kind of motion
transmitted to the implants during early phases of integration can
Compromise the long term results,/ if the threshold below which micro
motion may not compromise osseointegration
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The current trend is not to consider implant motion per se
detrimental to osseointegration , but rather to consider a
threshold of acceptable micro motion
Cameron & colleagues
Reported that Critical threshold level
50 µm & 150 µm
Dependent upon
Implant morphology &
Implant surface .
>150 µm micro motion should be excessive & therefore deleterious
For osseointegration
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Implant supported over dentures
Implant supported fixed prostheses
Immediate loading
Early loading
Edentulous
Mandible
Edentulous maxilla
Edentulous
Mandible
Edentulous maxilla
&
Results obtained from these combinations
journal issue from 1966 to 2006
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Immediate loading of implant supported over dentures
in the edentulous mandible
Preliminary observations
Immediately loading of a minimum of 4 implants rigidly connected
To bar placed in a inter foraminal area of mandible &loaded with
an implant supported over dentures seems not jeopardize the long
term survival & success rates of implants .
Good bone quality & primary stability seem to be important
prognostic factors for the success of the procedure ,
But more objective criteria , such as
Insertion torque valves ,
Resonance frequency analysis ,
Periotest analysis
Were rarely
Very used
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Early loading of implant supported over dentures
in the edentulous mandible
Preliminary observations
Early loading of implants supporting over dentures placed in a inter
foraminal region of the mandible seems not jeopardize the long term
survival & success rates of implants .
Both splinted & unsplinted implants seem to withstand the biomechanical
Demands of early loading , although lower success rates compare to
immediate implants
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Good bone quality & primary stability seem to be important
prognostic factors for the success of the procedure ,but evaluation of
these factors Is subjective therefore more objective measurements
criteria , such as
Insertion torque valves ,
Resonance frequency analysis ,
Periotest analysis
Should be used
Success & survival rates were comparable to conventional loading
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Bone quality can be assessed by measuring the cutting torque
during Preparation of implant
Stability of an implant & increasing bone to implant contact
Quantified by
Resonance Frequency Analysis
Measures the
Stiffness of the implant at the
Bone interface
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Immediate loading of implant supported fixed prostheses
in the edentulous mandible.
At least 4 implants are needed in the anterior mandible to support a
Fixed prostheses .
Primary stability with insertion torques up to 35 Ncm is an important
Factor for long term survival of implants .
Good bone quality (classes 1 to 3 ACCORDING TO LEKHOLM & ZARB
CLASSIFICATION) is an important factor for long term prognosis
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Immediate loading of implant supported fixed prostheses
in the edentulous maxilla .
The majority of authors suggest the following
A greater no. of implants are necessary in the maxilla than in the
mandible to support full arch prostheses.
Primary stability is suggested to be an important Factor for long term
survival of implants.
Good bone quality (classes 1 to 3 ACCORDING TO LEKHOLM & ZARB
CLASSIFICATION) is an important factor for long term prognosis,
But there is lack of objective measurements to evaluate implant
Stability
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Bone remodeling in immediately loaded & unloaded
Ti dental implants
Bone is a dynamic tissue ,& the long term maintenance of a rigid
Implant requires
Continuous remodeling at bone – metal interface
Activity serves to
Renew the interface & supporting bone
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Mechanical load plays an important role in the
development
maintenance
& adaptation of skeleton
Wolff’s law
gives connection between
Mechanical events
( stress, strain )
Bone biological events
(remodeling,
Formation ,
& resorption )
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Bone adaptation is dependent upon strain magnitude ,
Duration ,
Frequency,
History, type
& distribution
Immediate loading may the potential to increase density of
alveolar bone around endosseous implants .
New bone formation & active remodeling may be observed
When bone is mechanically stimulated .
Peri implant mineralized areas showed a higher density within
threads of immediately loaded implants
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Garetto reported that 50 to 60 % bone volume in the region
immediately adjacent to the implant with a much greater
remodeling rate in the adjacent regions .
Finite element analysis studies have shown that the region
Within 1 mm of the implant surface has a marked changes in
mechanical stress & distribution in both
Stress level
Stress gradient
Therefore loading within the physiologic limits can be speculated that
to stimulate bone formation as a result of bone adaptation to loading .
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Repetitive loading of bone leads to micro fracture ; such micro damage
Has been hypothesized to act as a stimulus to remodeling
Increase the remodeling in the region adjacent to an implant is
Apparently necessary to repair the local areas of the bone
micro damage
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Final observations
Loading appeared to stimulate bone remodeling at interface
Higher % of lamellar bone was found in the loaded implants
The % of bone labeling was higher at the loaded implants
Immediate loading had not interfered on the lamellar bone formation
& had not produced formation of woven bone at the interface
Successful maintenance of endossous implants involves a sustained
Increase of bone remodeling in the local region surrounding the implants
& that the bio mechanical environment of the interface may require a
Continuous remodeling to avoid bone fatigue fracture
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Immediate loaded implant systems
The strong initial stability in dense basal cortical bone
Achieved using
Diskimplants
Doms & scortecci
1985
Scortecci
1999
&
Modschiedler
1997
Use of diskimplants & structure implants
Has proven highly reliable & predictable
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In contrast , immediate loading of screw typed implants alone for
the edentulous maxilla
Predictable results only in
Limited situations
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Diskimplant ---cylindrical , stepped implant with basal disk
providing cortical support .
basal disk diameter ---8 mm
cylinders diameter ----2mm .
Hypothetical ---cylindrical , stepped implant with
diskimplants small basal disk providing
no cortical support .
basal disk diameter ---4 mm
cylinders diameter ----2mm .
Hypothetical diskimplants lies entirely in the cancellous bone
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Vertical & horizontal loading studied by using
Finite element analysis with different models
Like diskimplants , hypothetical diskimplants
& screw typed implants
Results obtained from these studies during vertical loading
In vertical axis
Diskimplants Hypothetical
Diskimplants
Screw typed
implants
Tensile stresses
--upper surface
Basal disk
Compression at the
Lower end of the
Screw threads
These zones are
Absent
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Horizontal axis
Diskimplants
Hypothetical
Diskimplants
Screw typed
implants
Tensile stress
Deformation
At the level basal disk
---75% greater than (DI)
Tensile stresses
Noted around the
end of the
Screw thread
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Horizontal loading
Zones of high compression & tensile stress were observed
with hypothetical diskimplants & screw implants
The compressive & tensile stresses at the shaft- cortical
bone junction were three times higher with screw typed
implants than diskimplant & hypothetical diskimplants .
Basal disk reduced at the level of shaft- cortical bone
junction ,while support in the reduced the degree of
compression in the cancellous
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FACTORS MAY INFLUENCE RESULTS OF IMMEDIATE
IMPLANT LOADING
SURGERY HOST IMPLANT OCCLUSION
Primary implant
stability ,
Surgical technique
Quality & quantity
Of cortical &
Trabecular bone ,
Wound healing ,
Modeling
& remodeling
activity
Surface texture ,
Design ,
dimension .
Quality &
quantity of
Force ,
Prosthetic
Design
HOST
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Implant related
factors
Implant design /
Configuration
Screw implant design develops higher mechanical
Retention as well as greater ability to transfer
compressive forces.
Screw design not only minimizes micro motion of
implant ,but also improve initial stability .,
Also threads increase the surface area
Studies have shown the absence of fibrous tissues
at the interface of screw shaped implants .
Due to it’s
Mechanical properties generally recommended for
Immediate loading
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Surgical related
factors
( primary implant
Stability )
Micro motion Bone implant contact
( BIC)
Concept of bicortical placement is valuable since
the higher surface of the fixture is engaged in
compact bone .
When primary stability is achieved & proper
prosthetic treatment plan is followed ,
Immediate functional loading is feasible .
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Surgical technique
Excessive surgical trauma & thermal injury
Leads to
Osteonecrosis
Fibrous encapsulation of implant
Results in
Heat – < 47 °C FOR 1 MIN
Interestingly ,increasing both the speed &
Load together allowed for more efficient
Cutting with no increase in temp
Operator experience may also indirectly
Influence the outcome of the treatment
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Host related
factors
Bone quality &
Quantity
Clinically , host bone density plays an important
Role in determining the predictability of the
immediate loading .
Compact dense bone is more likely to ensure
Initial stability & hence , better able to sustain
such immediate forces .
Cortical lamellar bone may heal with little
interim woven formation ,ensuring good bone
strength while healing next to an endosseous
implants .
In addition , it’s fine porosity favors better
mechanical interlocking compared to soft
cancellous bone
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Wound healing
Under optimal conditions it has been demonstrated
that only after 6 weeks of placement , lamellar
Bone was present at / near to implant .
The surrounding bone heals according to the cascade
Angiogenesis
Osteoprogenitor cell
Migration
Woven bone
Scaffold formation
Deposition of
parallel fibred/lamellar bone
Secondary bone remodelingwww.indiandentalacademy.co
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Implant design /
Configuration
For delayed loading protocol
Favorable clinical outcome
With
Cylinder type implants
Cylinder type implants would appear
contraindicated for immediate / early loading
protocols
Due to lowering of primary stability &
Less resistance to vertical movement &
shear stress
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Implant surface
coating
1991 –buser et al ---rougher implant surface
render a increase BIC .
Shear Strength of implants with a rougher
Surface was shown to be about 5 times as high as
Smooth surface implants
1993 –piattelli et al --- showed that a
mature compact bone was found around the
immediately loaded implants with 60-90%BIC
The reason for the clinical success regardless
of surface coating may be to the type of bone
utilized
m

Parameter like insertion torque , resonance frequency values
showed that threaded design was more of a determinant than
the surface characteristics for primary stability into softer bone
(type IV)
Implant length
For every 3mm increase in length
Surface area of cylinder
Shaped implant increase
By an average of 20 -30%
Length should be 10 mm long to ensure high success
Rate
Some authors mentioned use of >than 14mm in length
& >4mm in diameter for immediate loading
m

Occlusion related factors
Quantity & quality of
Force
Vertical forces applied during function are
less detrimental to implant stability rather
than oblique / horizontal forces
Occlusal over loading / bruxism has been
considered as a possible contraindication
for immediate loading
Occlusal load control is essential for
Maintaining success
m

Prosthetic design
Primary stability is enhanced when cross arch
Implant splinting is performed .
Majority of studies suggest that the cross
arch splinting as well as potential load &
movement caused by prostheses should be
avoided in immediate loading cases .
Careful occlusal analysis , such as
assessment of Para functional habits , &
distribution of occlusal support by remaining
teeth , is also essential when a loading
regimen for implants is considered
m

IMMEDIATE LOADING CAN BE POSSIBLE
IN ALL KIND OF SUITATIONS
?
m

References
(Books )
Contemporary Materials
&
Techniques
CHARLES –A –BABBUSH
IMPLANTS IN
CLINICAL DENTISTRY
BRAIN J SMITH ,
RICHARDS M PALMER
Implants &
restorative dentistry
GERARD M SCORTECCI
m

References
( journal )
JOURNAL OF
ORAL IMPLANTOLOGY
2005
INT J ORAL MAXILLOFAC
IMPLANTS
2005 ;20 :39 -47
DENTAL IMPLANTOLOGY
UPDATE
2006 ;17 :17 -21
2005 ;16 ;41 -45
INT J ORAL MAXILLOFAC
IMPLANTS
2006 ;21 :615 -622
J PERIODONTOL
2000;71 : 833-838
CLIN .ORAL IMPL.RES
2003;14:515- 527
J PROSTHET DENT
2005 ;94:242 -258
DENT CLIN N AM
2OO6; 50 : 339 -360
CLIN .ORAL IMPL.RES
2003;14:515- 527
J PERIODONTOL
2000;71 : 833-838
m

THANK YOU
For more details please visit
www.indiandentalacademy.com
m

Immediate implants/ esthetic in dentistry

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