implantology Flashcards
Dental implant
An artificial tooth root placed in the jaw to hold a replacement tooth or bridge
components of implants
- Crown: extra-gingival
- Abutment: transmucosal
- Implant Body: endosseous portion
implant levels
Bone level vs Tissue level
Bone Level Implants
* Connect at?
* Allows?
* which zone?
* Allows what # stages?
- Connect at bone
- Allows customized and angled abutments
- Esthetic zone
- Allows two-stage implant surgery
Tissue Level Implants
* Connect at?
* shaping soft tissue?
* staged surgery?
- Connect at soft tissue level
- Smooth neck shapes the soft tissue
- One-stage implant surgery
shapes of implants
cylindrical and tapered
cylindrical shaped implants
- Increased Surface Area
- Greater Force Transfer
- Most Common Design
conical shaped implants
- Complex osteotomy sites
- Root proximity
- Bone concavity
platform widths
std btwn 3.5-4.5mm
microgap
- Inflammatory cell infiltrate was consistently present at the level of the interface between the two components, the bone crest was consistently located 1-1.5 mm
apical of the microgap. - Inflammatory Infiltrate was due to bacterial contamination
platform switching
Platform switching is the concept of placing an narrower abutment on the wider implant to preserve
alveolar bone levels at the crest of a dental implant
how does platform switiching work
It reduces per-implant bone resorption at the bone crest and maintains the supracrestal attachment
* Increases distance of implant-abutment junction from the crestal bone
* Limits possible interface of bone with micro-movements
* Shifts the inflammatory cell infiltrate inward and away from the adjacent crestal bone
surface properties of implants
why would these be used?
Surface characteristic and roughness
Surface chemistry and surface free energy (SFE)
Enhance cell adhesion to get better osseointegration
ways to alter surface roughness
Roughness (Macro & Micro):
* Texture
* Machined
Substractive:
* Sandblast
* Acid-etch
Additive:
* Oxidation
* Coating
Smooth vs Rough Surfaces
moderately rough surfasces provided best osseointegration
issues with increasing roughness
the rougher the implant, the higher its’ Sa value
(in um), the easier for bacterial adhesion, the less efficacy of biofilm treatments
does microbial colonization always occur on implants based on roughness?
Microbial adhesion can occur on any implant surface,
regardless of the degree of surface roughness
Surface Chemistry And Surface Free Energy (SFE)
- SFE is the interaction between the force of cohesion and the force of the adhesion that determines whether or not wetting occurs.
testing SFE
- Sessile drop technique
- Different material, implant design with characteristics contribute to the SFE and cell/ bacterial adhesion.
factors of cell and bac adhesion to implant
definition of successful implants
A successful implant must present no mobility, no peri-implant radiolucency, bone loss less than 0.2 mm per year after the first year of loading, and no persistent pain, discomfort or infection
Landmarks to consider during implant placement
- Inferior Alveolar Canal/Mental Foramen
- Incisive Foramen
- Maxillary Sinus/Nasal Cavity
- Lingual undercut
Inferior Alveolar Canal And Mental Foramen implamnt recomendations
Premolar and molar areas of the mandible
A loop of the nerve can be found to extend mesially.
Safety zone of 3mm from the mental foramen and
2mm from the IAN is recommended.
best way to detect IAN/ mental foramen
CT, worst is PA
Incisive Canal implant considerations
Size and location are Important, may even graft canal for more bone
Maxillary Sinus/Nasal Cavity for implants
direct vs indirect lifting
Sinus augmentation may be needed
Direct sinus lifting: less than 4mm residual bone height
Indirect sinus lifting: more than 4mm residual bone heigh
Lingual Undercut and implants
- Perforating the lingual plate during preparation of the implant site can result in extensive and even life threatening bleeding.
- Proper planning and considering reflect a lingual flap to visualize the ridge
osseointegration
A direct functional and structural connection
between living bone and the implant surface
requirements of successful osseointegration
The stability of the bone at the time of implant
placement is critical to the successful osseointegration
Quantity: related to the degree of bone loss or bone resorption present
* Quality: related to the degree of bone density present
classes of bone quantitiy for implants
classes of bone quality for implants
2 and 3 are best
type 1 bone quality
Type 1: hard and dense like oak wood (D1)
* Less blood supply than other types (compact bone)
* Takes longer for an implant to integrate
* Found in the mandible
type 2 bone quality
Type 2: consistency of pine wood (D2)
* Thick layer of compact bone surrounds a core of
dense, trabecular bone
type 3 bone quality
Type 3: consistency of balsa wood (D3)
* Thin layer of cortical bone surrounds a core of
dense trabecular bone
type 4 bone quality
Type 4: consistency of Styrofoam (D4)
* Thin layer of cortical bone surrounds a core of low
density trabecular bone
* Commonly found in posterior maxilla
Concepts of implant Placement
Prosthetically-driven implant placement
Hard tissue management
Soft tissue management
Prosthetically-driven Implant
Placement considerations
Safety/ Function/ Value/ Esthetics
space req for implants in MD deminsion
- At least 1.5 mm between teeth and implant
- At least 3 mm between 2 adjacent implants
results of lack of space btwn implants
can’t restore, no access to clean, bone loss, peri-implantitis
BL deminsion implant considerations
- Significantly greater resorption and gingival recession when the ridge width < 2 mm.
- Anterior region: at least 2 mm of buccal bone thickness
- Posterior region: at least 1mm buccal bone and 1mm lingual bone thickness is acceptable
coronal apical deminsions for implants
- 3-4mm from adjacent CEJ
- It is recommended to place bone level implants subcrestally
classes of ridge atrophy
hard tissue management
- Ridge atrophies: horizontal and vertical
- Siebert Classification:
- Class I: buccolingual loss of tissue (horizontal)
- Class II: apicocoronal loss of tissue (vertical)
- Class III: both loss of tissue
options for ridge augmentation for implant placement
- Ridge augmentation for atrophic bony ridge
- Bone block technique vs particulate bone graft
- Guided Bone regeneration (GBR): A surgical procedure that uses barrier membranes with bone grafts to augment atrophic bony ridge
- Sinus augmentation: direct/indirect
complications of ridge augmentation:
healing?
postop?
tx time?
- Longer healing time: 3-12 months to be ready for implant placement, depending on the augmented volume, the graft material and individual healing ability.
- Post-op complications: membrane exposure, infection, sinus membrane perforation…etc.
- Longer expected treatment time line
Rationales for RIDGE PRESERVATION:
* Maintain? esthetics?
* Simplify?
* Ready for implant placement at?
- Maintain stable ridge volume to optimize functional and esthetic outcomes (decreased atrophy)
- Simplify treatment procedures following the ridge preservation
- Ready for implant placement at 3-6 months
- Peri-implant mucosa
- The soft tissue surrounding
dental implants
- Transmucosal attachment of implants
- A mucosal seal should prevent bacterial products reaching the bone, ensuring the osteointegration
The height of the peri- implant supracrestal soft tissue (PST) includes:
sulcular epithelium, junctional epithelium and supracrestal connective tissue
Supracrestal tissue attachment for implants
Supracrestal tissue attachment is roughly 3 mm
(JE 1.88 mm + CT 1.05 mm =2.93 mm)
soft tissue thickness needed to prevent dihesence in implants
- Soft tissue thickness greater than 2 mm is necessary to prevent peri- implant soft tissue dehiscence
- A minimum of ? mm of KT is necessary to facilitate
proper oral hygiene for peri- implant health
- A minimum of 2 mm of KT
is necessary to facilitate
proper oral hygiene for peri-
implant health
graft to gain KT?
free gingival graft
graft to gain thickness?
conn tissue graft
tooth vs implant perio support
* contact w bone?
* Peri-implant fibers?
* Ankylosis?
* Blood supply?
* inflammatory response?
- Direct bone to implant contact (osseointegration)
- Peri-implant fibers form parallel cuff in a oriented longitudinal direction
- Ankylosis, higher stress at the neck of the screw/implant
- Blood supply by terminal branches of large vessels from periosteum, fewer capillaries.
- Stronger inflammatory response (in implant)
peri implant fibers:
* Peri-implant fibers form?
* Epithelial cells attached by?
* Collagen fibers insertion?
* Prevents?
- Peri-implant fibers form parallel cuff in a oriented longitudinal direction
- Epithelial cells attached by hemidesmosomes
- Collagen fibers do not insert into the implant but
creates a cuff around the implant creating a mucosal seal - Prevents bacterial invasion
inflammation in implants
- Stronger inflammatory response
- Similar to periodontitis, peri-implantitis lesion is
dominated by plasma cells and lymphocytes but
characterized by a larger proportion of PMNs and macrophages - Area proportions, numbers and densities of
plasma cells, macrophages and neutrophils are
higher in peri-implantitis
Peri-implant health
Absence of erythema, bleeding on probing, swelling and suppuration
Peri-implant mucositis
An inflammation in absences of continuous marginal peri- implant bone loss. The clinical sign of inflammation is bleeding on probing. Additional signs may include erythema, swelling, and suppuration.
Peri-implantitis
A pathological condition occurring in tissues around dental implants, characterized by inflammation in the peri-implant mucosa and progressive loss of supporting bone. Clinical sign of inflammation is detected by bleeding on probings, while progressive bone loss is identified on radiographs
Prevalence of peri-implant mucositis and implantitis
- 43% for peri-implant mucositis and 22% for peri-implantitis at subject level
- 29.5% for peri-implant mucositis and 9.3%-22.1% for peri-implantitis at implant level
Diagnosis of implant conditions
with previous data available
- Baseline X-ray or previous examination data is available
- Presence of bleeding and/or suppuration on gentle probing.
- Increased probing depth compared to previous examinations.
- Presence of bone loss beyond crestal bone level changes resulting from initial bone remodeling ( ≥2 mm after the 1st year of function
diagnosis implant conditions without previous data
- In the absence of previous examination data :
- Presence of bleeding and/or suppuration on gentle probing.
- Probing depths ≥6 mm.
- Bone levels ≥3 mm apical of the most coronal portion of the intraosseous part of the implant
comparing implant health, mucositis and implantitis: inflam, BoP/SoP, bone, PD
Peri-implantitis risk factors/Indicators
* plaque control?
* Lack of?
* Tissue quality?
* Iatrogenic factors:
* cement?
* Occlusa?
* Titanium?
- Poor plaque control
- Lack of regular maintenance
- Tissue quality: thin phenotype, KT band, bone deficiency
- Iatrogenic factors: malpositioning, poor design of emergency profile, inadequate abutment/implant seating
- Excessive cement
- Occlusal overload
- Titanium particles: implant corrosion, micromovemen
Peri-implantitis risk modifiers
- History of periodontal disease
- Smoking
- DM
- Genetic factors
- systemic condition
Microbiology of implant colonization
red complex?
- Bacterial colonization was initiated within 30 min after implant placement.
- The sequence of colonization on dental implants and biofilm formation is similar to that of teeth.
Red complex: T. forsynthia, P.gingivalis, T. denticola
progression thru peri implant dx’s
- Plaque leads to peri-implant mucositis
- Plaque accumulation and then reversed
- Histology demonstrated B & T cells infiltration at 21 days
- Peri-implant mucositis may lead to peri-implantitis
- It mirrors the progression of gingivitis to periodontitis
Implants in Fully Edentulous Patients microbio
- The microbiota is similar to the mucosal flora on
the adjacent alveolar ridge - Over 80% were Gram- positive facultative cocci
- Spirochetes were limited
- Fusobacteria/black- pigmenting Gram- negative anaerobes were found infrequently
Implants in Partially Edentulous Patients microbio
- The microbiota is similar to remaining teeth
- Higher percentages of black-pigmenting Gram- negative anaerobes and Capnocytophaga
perio dx tx when implant is planned?
tx before implant placed
exposure of implant surface may lead to?
- Surface topography influences biofilm formation
- Exposure of the implant surface may lead to peri-implantitis due to colonization
Maintenance of implants
* Provide?
* Focus on what tissues?
* Work as?
- Provide guidelines for maintaining the long term
health of the dental implant - Focus on both hard and soft tissue stability
around the dental implant - Work as a team— patient are co-therapists in the
maintenance therapy
Maintenance oral hygiene mods
Oral Hygiene Modification
Interproximal brushes can effectively penetrate up to 3mm into a gingival sulcus and may effectively clean a
peri-implant sulcus
professional debridment of implants
Scalers made of stainless steel and ultrasonic tips can roughen the implant surfaces creating scarring and pitting
surgical management of failing implant
Implantoplasty and osseous surgery (regenerative surgery)
