Implant surgeries to overcome anatomic difficulties/certified fixed orthodontic courses by Indian dental academy
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Implant surgeries to overcome anatomic difficulties/certified fixed orthodontic courses by Indian dental academy
23 de Jul de 2016•0 recomendaciones•555 vistas
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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.for more details please visit www.indiandentalacademy.com
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Implant surgeries to overcome anatomic difficulties/certified fixed orthodontic courses by Indian dental academy
- 1. IMPLANT SURGERIES TO OVERCOME ANATOMIC DIFFICULTIES INDIAN DENTAL ACADEMY Leader in continuing Dental Education www.indiandentalacademy.com
- 2. CONTENTS INTRODUCTION GUIDED TISSUE REGENERATION. RIDGE AUGMENTATION. MAXILLARY SINUS LIFT TECHNIQUE INFERIOR ALVEOLAR CANAL LATERALIZATION MENTAL NERVE DISTALIZATION CONCLUSION BIBILOGRAPHY www.indiandentalacademy.com
- 3. INTRODUCTION The goal of modern dentistry is to restore the patient to normal contour, function, comfort, esthetics, speech and health regardless of the atrophy, disease or injury of the stomatognathic system. As a result of continued research in treatment planning, implant designs, materials and techniques predictable success is now reality for rehabilitation of many challenging clinical situation. www.indiandentalacademy.com
- 4. Various techniques to over come anatomic difficulties are: 1. Guided tissue regeneration. 2. Ridge augmentation. 3. Maxillary sinus lift technique 4. Inferior alveolar canal lateralization 5. Mental nerve distalization www.indiandentalacademy.com
- 5. Guided tissue regeneration : It is a process used in regeneration of periodontal supporting structures around natural tooth that have been lost as a result of inflammatory diseases or trauma - MELCHER www.indiandentalacademy.com
- 7. Barrier to prevent other tissues, Provide additional wound coverage, and provide added stability and protection of the blood clot. a tent- like area. www.indiandentalacademy.com
- 8. The principles of membrane barrier techniques are to facilitate: 1. Augmentation 2. Improve bone healing 3. complete bone regeneration, 4. Improve bone grafting results, and 5. Treat failing implants www.indiandentalacademy.com
- 9. Indications Various implant defects Fenestrations Dehiscence Residual intra osseous defect Extraction socket defect www.indiandentalacademy.com
- 12. Materials used Non-resorbable 1. cellulose filter ( millipore) 2. e-PTFE (goretex) www.indiandentalacademy.com
- 13. Resorbable Degradation through enzymatic activity (biodegradation) or hydrolization (bioabsorption) as a cellular response from the surrounding tissue. They include 1. collagen membranes, 2. polylactic acid, 3. polyglycolic acid, 4. synthetic liquid polymer, 5. polyglactin, 6. calcium sulfate. www.indiandentalacademy.com
- 14. RIDGE AUGMENTATION CAWOOD AND HOWELLS www.indiandentalacademy.com
- 15. Aims Restoration of optimum : Protection interarch relationship. retention and stability patient comfort. www.indiandentalacademy.com
- 17. Graft materials Autogenous bone graft – iliac crest, rib grafts Allogenic bone grafts – freeze dried cadaver bone. Alloplastic material – hydroxyapatite Metal mesh with autogenous cancellous bone. Metal mesh with hydroxyapatite www.indiandentalacademy.com
- 18. MANDIBULAR AUGMENTATION Augmentation procedures : 1. superior border grafting 2. inferior border grafting 3. interpositional bone graft 4. visor osteotomy 5. onlay grafting. www.indiandentalacademy.com
- 19. SUPERIOR BORDER GRAFTING Davis Two 15 cm autogenous rib grafts www.indiandentalacademy.com
- 20. DISADVANTAGES Second surgical site necessary. Continued resorption of the grafted sites. Soft tissue dehiscence or limitation donor site morbidity www.indiandentalacademy.com
- 21. INFERIOR BORDER GRAFTING Indicated when ridge height is less than 5-8mm and risk of pathological fracture. Used for reconstruction of mandible following resection, augmentation of atropic ridge and subsequent placement of implants www.indiandentalacademy.com
- 22. Supraclavicular incision from mastoid to mastoid region. www.indiandentalacademy.com
- 23. ADVANTAGES patient's old dentures can be used as transitional dentures 11 to 17 mm of bone augmentation resorption rate of only 5 per cent over the first several years. Increased bone height adequate tissue coverage www.indiandentalacademy.com
- 24. Interpositional Bone Grafts Sandwich Grafting a horizontal osteotomy In mandible, sandwich technique is mainly used Delivery of the prosthetic appliance is delayed 3 to 5 months for allowing the remodeling of the bone. www.indiandentalacademy.com
- 25. Advantages Less resorption rate than onlay grafting. More predictable long-term results. Decreased incidence of nerve paraesthesia than the visor osteotomy. Can be used in conjunction with osseointegrated implants. www.indiandentalacademy.com
- 26. Onlay Grafting Done when adequate height but inadequate width. Two techniques 1. Oldest technique www.indiandentalacademy.com
- 27. Advantages • Improves the height and width of the maxillaryalveolar bone • Can be used both in the anterior and posterior region. www.indiandentalacademy.com
- 28. Technique 2 : . www.indiandentalacademy.com
- 30. Visor Osteotomy Advantage Eighty percent of the height is maintained at the end of 3-5 years. Disadvantages Nerve paraesthesia and dysesthesia. Need for hospitalization. Donor site morbidity. Inability to wear the dentures for 3 to 5 months following surgery. www.indiandentalacademy.com
- 31. Modified Visor Osteotomy . www.indiandentalacademy.com
- 32. SINUS LIFT TECHNIQUE Hilt Tatum. Bob James, and Phil Boyne, is not the same procedure performed today. www.indiandentalacademy.com
- 33. Currently, the procedure that is being performed in contemporary implant reconstruction for the posterior maxilla is more accurately labele the maxillary antroplasty with augmentation bone grafting. www.indiandentalacademy.com
- 34. INDICATIONS Implant placement in areas of insufficient bone volume Oroantral fistula repair. Alveolar cleft reconstruction. Cancer reconstruction for craniofacial prostheses. www.indiandentalacademy.com
- 35. GENERAL MEDICAL CONTRAINDICATIONS 1. Radiation treatment to the maxillary region. 2. sepsis 3. Severe medical fragility. 4. uncontrolled systemic disease 5. excessive tobacco abuse 6. excessive alcohol or substance abuse 7. Psycophobias. www.indiandentalacademy.com
- 36. LOCAL FACTORS Maxillary sinus infections Chronic sinusitis Odontogenic infections Inflammatory or pathologic lesions Severe allergic rhinitis www.indiandentalacademy.com
- 39. The bone graft material is placed into the sinus. www.indiandentalacademy.com
- 41. Category 2 surgery The newly formed bone, and the elevated sinus floor. www.indiandentalacademy.com
- 42. Benefits Reconstruct the highly atrophic posterior maxilla Replace the patient's removable prosthesis Stabilize the anterior residual dentition by reconstructing the entire arch Reduce the continuous progressive atrophy of the posterior alveolar ridge www.indiandentalacademy.com
- 43. complications Sinus membrane perforation is a complication of sinus elevation surgery. in this image a small (1-2 mm) perforation can be observed A large perforation was created by removal of the bony window with the underlying sinus membrane. In a case of such a large perforation, the sinus elevation procedure should be aborted. www.indiandentalacademy.com
- 44. Complications Dehiscence with loss of the graft material Dehiscence with exposure of the barrier membrane Infection Potential loss of implants www.indiandentalacademy.com
- 45. GUINDELINES to follow for sinus grafting for dental implants may also include the following: alveolar residual bone height of less than 10mm less than 4mm of residual bone width no history of pathosis No significant history of sinus disease. No anatomic limitations presented by anatomic structures or scarring after previous surgery www.indiandentalacademy.com
- 46. Gaber et al did a study on potential alterations of voice quality following sinus elevation For the majority of patients, slight changes of the voice pattern are of no importance. However, for voice professionals, whose voices have become part of their distinctive profession or trademark, minimal changes may have dramatic consequences. This specific group of patients, such as speakers, actors and singers, depend on the particular quality and timbre of their voice for their livelihood. www.indiandentalacademy.com
- 47. INFERIOR ALVEOLAR NERVE LATERALIZATION www.indiandentalacademy.com
- 48. NERVE ANATOMY Solar documented Two different types of intraosseous path of the mental nerve www.indiandentalacademy.com
- 54. DISTALIZATION OF THE MENTAL NEUROVASCULAR BUNDLE www.indiandentalacademy.com
- 55. LIMITATIONS These procedures are technically difficult and therefore not suited for every doctor. Implant practitioners who have the clinical experience, anatomic knowledge, and ability to treat potential interoperative and postoperative complications are the only ones equipped to perform these procedures. Nerve damage is a significant risk of the procedures. Both the surgical manipulation of the neurovascular bundle and the overall surgical procedure can cause postoperative nerve deficits. www.indiandentalacademy.com
- 56. Each patient should be advised of the risk for permanent nerve deficits, which include anesthesia, paresthesia, dyses thesia, and hyperesthesia. Fracture of the mandible, although rare, is also a risk. The vast majority of these patients have advanced degrees of atrophy in this area of the mandible. www.indiandentalacademy.com
- 57. CONCLUSION Patients undergoing these procedures usually displays post operative neurologic deficiency. Periodic assessment of these patients are utmost important. Without the benefits of CT scans and three dimensional reformatted imaging, these techniques are difficult, if not impossible, to perform. However, this technology has made these procedures a viable option when performed by a skilled and knowledgeable surgeon in appropriately selected cases. www.indiandentalacademy.com
- 58. BIBLIOGRAPHY Charles A.Babbush: Dental Implants The Art and Science. Carl. E. Meish – Implant dentistry Block Kent Guerra: Implants in Dentistry Essentials of Endosseous Implants for Maxillofacial Reconstruction. Block: Color Atlas of Dental Implant Surgery. Neelima Anil Malik: Textbook of Oral Maxillofacial Surgery Jensen: The Sinus Bone Graft. www.indiandentalacademy.com
- 59. Charles A.Babbush ; Transpositioning and repositioning the inferior alveolar and mental nerves in conjunction with endosteal implant reconstruction; Periodontology 2000, Vol. 17, 1998, 183-190 Ellegaard et al; Implant therapy involving maxillary sinus lift in periodontally compromised patient; Clin Oral Impl Res 1997;8;305315 . Eliaz Kaufman: Maxillary Sinus Elevation Surgery: An Overview; j Esthet Restor Dent 2003; 15:272283 Gabor et al: Effects of sinus lifting on voice quality: Clin. Oral Impl. Res. 14, 2003 / 767–774 . www.indiandentalacademy.com
Notas del editor
- INTRODUCTION GUIDED TISSUE REGENERATION. RIDGE AUGMENTATION. MAXILLARY SINUS LIFT TECHNIQUE INFERIOR ALVEOLAR CANAL LATERALIZATION MENTAL NERVE DISTALIZATION CONCLUSION BIBILOGRAPHY
- The goal of modern dentistry is to restore the patient to normal contour, function, comfort, esthetics, speech and health regardless of the atrophy, disease or injury of the stomatognathic system. As a result of continued research in treatment planning, implant designs, materials and techniques predictable success is now reality for rehabilitation of many challenging clinical situation
- Various techniques to over come anatomic difficulties are: Guided tissue regeneration. Ridge augmentation. Maxillary sinus lift technique Inferior alveolar canal lateralization Mental nerve distalization
- It is a process used in regeneration of periodontal supporting structures around natural tooth that have been lost as a result of inflammatory diseases or trauma - MELCHER
- Barrier to prevent other tissues Especially connective tissue, from entering the intended site of bone reformation and from interfering with osteogenesis and direct bone formation Provide additional wound coverage, And provide added stability and protection of the blood clot. Also provide a tent like area for the blood clot, Creating a space under the surgical flap that will act as the scaffold for ingrowth of cells and blood vessels from the base of the lesion.
- The principles of membrane barrier techniques are to facilitate: Augmentation of alveolar ridge defects Improve bone healing around dental Implants, Induce complete bone regeneration, Improve bone grafting results, and Treat failing implants
- Various implant defects Fenestrations Dehiscence Residual intra osseous defect Extraction socket defect
- expanded polytetrafluoroethylene - . e-PTFE (goretex)
- Order I - pre extraction Order II - post extraction Order III - high well rounded Order IV - knife edge Order V - low well rounded Order VI - depressed
- Restoration of optimum : Ridge height and width, Ridge form, Vestibular depth Optimum denture bearing area Protection of neurovascular bundle Establishment of proper interarch relationship. Improvement of retention and stability of denture. Improve the patient comfort for wearing the denture.
- Physical condition of the patient Metabolism of the patient (healing capacity) Nutritional deficiencies. Inadequate soft tissue coverage. Compliance of the patient for major surgery
- Davis (1970) has described a technique for ridge augmentation, that uses two 15 cm autogenous rib grafts. One rib is scored at the cortex, followed by contouring the same rib in the shape of the mandible. The rib graft is fixed to the mandible, either with transosseous wiring or circum-mandibular wiring. The other rib graft is made into corticocancellous particles and moulded around the first rib graft. The surgical flap is then closed. Iliac crest grafting to the superior border also can be used.
- First described by Marx and Saunders (1986) for reconstruction of the mandible following resection. Modified by Quinn (1991) - used for augmentation of atrophic ridge and subsequent placement of implants Indicated when ridge height is less than 5-8mm and risk of pathological fracture. Used for reconstruction of mandible following resection, augmentation of atropic ridge and subsequent placement of implants
- A supraclavicular incision similar to the incision used in bilateral neck dissection is made, from mastoid to mastoid region. Subplatysmal dissection, till the inferior border of the mandible is done. Incision through the periosteum is completed from angle to angle. A freeze-dried allogenic cadaver mandible is hollowed out and multiple perforations made into it to allow for revascularization of the packed cancellous bone graft. This allogenic mandible will be used as a tray. The cancellous bone graft is harvested from the iliac crest. The cadaver mandible is then filled with autogenous cancellous graft particles and is fixed to the inferior border with 2-0 vicryl sutures, by circummandibular fixation. The neck flap is closed in tension free manner. Osseointegrated implants can be placed approximately 4-6 months following surgery
- Since no surgery is done intraorally, patient's old dentures can be used as transitional dentures By using this technique 11 to 17 mm of bone augmentation can be achieved with a resorption rate of only 5 per cent over the first several years. Increased bone height to accommodate implant surgery Extraoral flap gives adequate tissue coverage
- During this procedure, a horizontal osteotomy is performed, splitting of the residual maxilla or mandible and bone is grafted into this osteotomy gap. In mandible, sandwich technique is mainly used for augmentation of the anterior mandible, between the mental foramina. The autogenous or allogenic bone or hydroxyapatite grafts can be used successfully. Delivery of the prosthetic appliance is delayed 3 to 5 months for allowing the remodeling of the bone.
- Less resorption rate than onlay grafting. More predictable long-term results. Decreased incidence of nerve paraesthesia than the visor osteotomy. Can be used in conjunction with osseointegrated implants
- Oldest technique for onlay augmentation with hydroxyapatite advocated via submucosal vestibuloplasty technique. After creating a tunnel via midline, a putty is formed of hydroxyapatite crystals, mixed with saline/blood, and is injected via syringe into the submucosal tunnel. The hydroxyapatite powder can be mixed with autogenous bone graft particles. A split thickness rib graft/iliac crest bone graft can be used, as an onlay graft in the maxilla or mandible. Rib is more uniform and can be placed in one piece. Iliac crest is placed in blocks or pieces, not uniform.
- Improves the height and width of the maxillaryalveolar bone • Can be used both in the anterior and posterior region
- A high vestibular incision is given and mucoperiosteal flap is reflected to expose the defect. Small perforations are made in the external cortex by using small round bur to create bleeding and promotion of clot formation and neovascularization. The grafting material is placed/ moulded over the external cortex. Placement of barrier membrane helps in regeneration and preservation of the graft
- The goal of Visor osteotomy is to increase the height of the mandibular ridge for denture support The Visor osteotomy consists of central splitting of the mandible in buccolingual dimension and the superior positioning of the lingual section of the mandible, which is wired in position. Cancellous bone graft material is placed at the outer cortex over the superior labial junction for improving the contour.
- Advantage Eighty percent of the height is maintained at the end of 3-5 years. Disadvantages Nerve paraesthesia and dysesthesia. Need for hospitalization. Donor site morbidity. Inability to wear the dentures for 3 to 5 months following surgery.
- Consists of splitting of mandible buccolingually by vertical osteotomy only in the posterior regions and a horizontal osteotomy in the anterior region. The posterior lingual segments are then pushed superiorly on both the sides and anterior fragment is also pushed superiorly and fixed with wires to the posterior newly mobilized lingual segments. Corticocancellous bone graft particles with hydroxyapatite granules is placed in the gap between the superior and inferior anterior segments. Rest of the graft material can be moulded on the buccal aspect of the posterior segments
- The maxillary sinus lift grafting procedure that was originally designed and described by Hilt Tatum, Bob James, and Phil Boyne, is not the same procedure performed today. The original method was one in which an endosteal blade-vent implant was positioned in the atrophic posterior maxilla. This was achieved by creating a groove in the atrophic alveolar ridge using a high-speed contra-angle drill with a no. 700 or no. 700 XL bur. When the channel was completed, a large type of Omnii blade-vent implant was positioned in the bony channel, and a mallet was used to fracture the floor of the sinus cavity in a superior direction. The vents of the blade-vent implant in many instances were filled with various types of bone grafting material before it was placed in its final position in the bony channel.
- Currently, the procedure that is being performed in contemporary implant reconstruction for the posterior maxilla is more accurately labeled a maxillary antroplasty with augmentation bone grafting. The procedure involves making an osteotomy in the lateral sinus wall and changing the configuration of the maxillary antrum by rotating the osteotomized window medially and superiorly. The schneiderian membrane is elevated, creating an empty chamber superior to the residual alveolar bone. The newly created space is then augmented with various types of bone graft materials These materials, which may be autografts, allografts, alloplasts, or a combination thereof, are placed into the area previously occupied by the sinus membrane, which builds up the posterior maxillary alveolar atrophic ridge from within the sinus boundaries
- Implant placement in areas of insufficient bone volume Oroantral fistula repair. Alveolar cleft reconstruction. Cancer reconstruction for craniofacial prostheses.
- GENERAL MEDICAL CONTRAINDICATIONS Radiation treatment to the maxillary region. Sepsis Severe medical fragility. uncontrolled systemic disease excessive tobacco abuse excessive alcohol or substance abuse Psycophobias.
- LOCAL FACTORS Maxillary sinus infections Chronic sinusitis Odontogenic infections Inflammatory or pathologic lesions Severe allergic rhinitis
- Two categories- categorie 1: stages surgery, less than 3-5 mm of bone is left categorie 2: single staged surgery, more than 3-5 mm of bone is left
- The porous HA alloplast and the freeze-dried cortical cancellous allograft are mixed in a 1:1 ratio. The newly harvested autogenous cancellous bone particles are then added to the combined allograft-alloplast material, again In a 1:1 ratio, to complete the graft composition. The mixture is placed into a bone graft cup . Firm packing of the graft material should be obtained to create the best density of graft and subsequent bone Barrier membranes are then trimmed and contoured to fit over the osseous receptor site. These membranes should always be placed between the mucoperiosteal flap and the underlying osseous surface. At least two IMZ membrane tacks are used to fix the membrane in position, thereby reducing the potential for micromovement.
- The mucoperiosteal flap is repositioned and sutured with interrupted 4-0 compatible Gore-Tex® or other suture material of choice. Because of the nature of this material, multiple knots are required to prevent spontaneous loss of the sutures. Once suturing of the mucoperiosteal flaps is complete, the patient's existing denture is radically relieved in the areas of surgical intervention and relined with either Viscogel or Lynal. T he graft is allowed to mature over a 6-month period, at which time implant placement is performed. If resorbable membranes are used, there is no need to remove them or the stabilizing tacks.
- INDICATIONS LIMITATIONS Limiting factors include the following: These procedures are technically difficult and therefore not suited for every doctor. Implant practitioners who have the clinical experience, anatomic knowledge, and ability to treat potential interoperative and postoperative complications are the only ones equipped to perform these procedures. Nerve damage is a significant risk of the procedures. Both the surgical manipulation of the neurovascular bundle and the overall surgical procedure can cause postoperative nerve deficits. Each patient should be advised of the risk for permanent nerve deficits, which include anesthesia, paresthesia, dysesthesia, and hyperesthesia. Fracture of the mandible, although rare, is also a risk. The vast majority of these patients have advanced degrees of atrophy in this area of the mandible.
- observed in 37 dried human specimens. Two different types of pathways were documented. In 22 cases, Based on these data, it is recommended that a distance of at least 6 mm anterior to the mental foramen be maintained when performing surgery in this region.
- The inferior alveolar canal is usually 2 mm below the level of the mental foramen in its distal path through the body of the mandible. It then turns superiorly as it tracks to exit at the mental foramen A no. 700 or 701 bur in a straight hand piece with high torque and copious amount of irrigation is recommended to prepare the osteotomy site. Combinations of straight and curved chisels, specifically designed for this procedure, are used to separate the residual bony bridges and remove the bony window
- The Nerve Hook retractor is specially designed to free the inferior alveolar nerve from its position in the canal. Any osseous spicules are removed from the area with great care. An umbilical tape or neurologic elastic-type retractor is passed around the nerve bundle and used to lateralize and retract the neurovascular bundle.
- Preparation of the osseous receptor site using appropriate burs for the placement of the implants is then initiated. The apical end of the preparation must be positioned inferior to the osteotomy site toOnce the implants have been placed, the nerve is repositioned over the lateral aspect of the Implants. There is no thermal conduction from the Implant to the nerve. Once the osseous defects around the implants have been filled, the mucoperiosteal tissues are repositioned and closed with interrupted sutures of choice