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BDS4 Implant Symposium > Planning and Placement > Flashcards

Planning and Placement Flashcards

1
Q

What is Osseointegration?

A

A direct functional and structural connection between a load bearing dental implant and living (organised) bone.

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2
Q

What are the 2 phases of osseointegration with implant and bone?

A

First phase- implant is held in by mechanical locking of threads into bone (friction fit)

Second phase- functional connection- bone grows into thread (integrated surface)
-> Initially the threads are empty apart from blood clot, as it reorganises and become vascularised it can then develop into osteoid and mature bone

Bone-implant contact- measure of osseointegration

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3
Q

How do implants and tooth differ in terms of supra-crestal tissue?

A

Tooth
- More fibroblasts
- Less collagen
- Collagen fibres orientated perpendicular to root surface

Implant
- More collagen
- Less fibroblasts
- Collagen fibres orientated parallel to implant crown

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4
Q

How do implants and tooth differ in terms of sub-crestal tissue?

A

Tooth
- Anchored to bone by periodontal complex (bone/PDL/cementum)
- Capable of physiologic adaption (viscoelastic)
- “Resilient” tissue attachment

Implant
- Implant anchored to bone by direct functional contact
- No Physiologic adaption present
- Rigid connetion

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5
Q

What materials are used in implants?

A

Titanium- pure type 4 (>85%)

Titanium- zirconia (85:15)
-> Stronger than Ti

Ceramic- ytrria-stablised zirconia
-> tooth coloured/high survival rate

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6
Q

What are the different aspects of implant design?

A

Bone or tissue level

Tapered or Parallel

Narrow, wide, regular
-> diameter

Length

Surface texture- machined or treated?

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7
Q

When are bone/tissue level implants used?

A

Bone level commonly used in aesthetic zone
-> more space to modify emergence profile

Tissue level used posteriorly

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8
Q

When may tapered implants be preferred?

A

Tapered may provide increased primary stability in immediate placement

Tapered may be used where there is root convergence apically

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9
Q

What factors determine which size of implant to use?

A

Site

Indication

Local anatomy

-> narrower/shorter tend to have high survival

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10
Q

What levels of roughness can implants be available in?

A

Smooth (0-0.5um)

Mild (0.5-1um)

Moderately (1-2um)

Rough (>2um)

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11
Q

What treatments can be done to roughen surface of implants?

A

Sand blasting

Acid etch

Plasma spray

-> allows reparative osteocytes to grow into implant and provide connection

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12
Q

What is the function of a dental implant?

A

Replace missing teeth
- Functionally
- Aesthetically
- Psychologically (difficulty tolerating dentures)

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13
Q

What are the primary aims of implant treatment?

A

Replace missing teeth with aesthetic, functional and predictable restoration

Low rate of complications during healing and maintenance period

Long term stability

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14
Q

What should be assessed when considering removal of teeth to replace with dental implants?

A

Prosthetic value of the tooth

Periodontal status

Endodontic status

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15
Q

What is used to determine the complexity of a case when considering dental implants?

A

SAC guidelines
-> low, medium, high risk

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16
Q

What should we ask/tell the patient about dental implants when considering their aesthetic demand?

A

Will implants address the patients presenting complaint
I.e. if they do not want a removable prosthesis is a fixed implant supported prosthesis possible?

What is the patients expectation?

Are they realistic?

Can you achieve them with implants?

Implants are not a panacea

Implant restorations are often not as aesthetic as natural teeth

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17
Q

What are the categories for a patients aesthetic demand as per SAC?

A

Low

Medium

High

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18
Q

What must we consider in terms of medical health when selecting a case for implants?

A

ASA class

Haematological isses

Medications- SSRIs, PPIs, bisphosphonates, steroids

Radiotherapy

CVD

Poorly controlled diabetes

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19
Q

What are the categories for medical health in terms of SAC?

A

Low- healthy, intact immunes system

High- reduced immunes system

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20
Q

What does smoking affect in terms of dental health?

A

Vascularity
Fibroblast/Osteoblast function
PMN function

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21
Q

How does smoking affect implants?

A

Increased risk of implant failure

Increased risk of peri-implantitis

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22
Q

What are the risk classifications for smoking as per SAC?

A

Low- non-smoker

Medium- <10 per day

High- >10 per day

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23
Q

What aspects of dental history may be considered when assessing suitability for implants?

A

Patient attendance

Motivation

Self performed plaque control

Past tx

Suitable for a surgical procedure

Presence of bruxism- increased risk of failure due to screw fractures, porcelain fractures, implant fractures, framework fractures

24
Q

What issues can occur when you place implants in patient who has not stopped growing?

A

Relative infra-occlusion

Suboptimal aesthetics

Occlusal disharmony

Implant fenestration

-> Delay until at least 21 years of age

25
Q

What are the different smile lines?

A

High- >2mm ST show (unforgiving, minor errors will be obvious)

Medium- <2mm ST show

Low- lip covers >25% of teeth

26
Q

What intra-oral checks should be done when assessing suitability of a patient for implants?

A

Presence of incisal cants

Presence of gingival cants

Width of aesthetic zone

27
Q

What extra-oral checks should be done when assessing suitability of a patient for implants?

A

Skeletal relationship
-> Will impact on positioning of prosthetic tooth and therefore implant 3d position
-> May impact on occlusal forced on tooth and guidance

28
Q

What are the gingival phenotypes and which category are each in terms of SAC?

A

Low risk- thick, low scalloped

Medium- medium thickness, medium scalloped

High risk- Thin, highly scalloped

29
Q

In terms of shape of crown what is considered high and low risk in SAC?

A

High- triangular

Low rectangular

30
Q

How is risk of Black triangle formation between implants and adjacent teeth determined?

A

Depends on relative height of alveolar bone in relation to contact point
- If this is more than 7mm (high risk of black triangle)
- 5.5mm-6.5mm (increased/medium risk)
- <5mm- full papilla infill (low risk)

31
Q

What aspects of soft tissue should be assessed before placing an implant?

A

M-D papilla

Gingival zenith

Mucosal contour/deficiency

ST colour and texture

32
Q

How does local presence of infection at site of implant placement affect a patients suitability for implants?

A

Low risk- none

Medium risk- chronic infection

High risk- acute

33
Q

How can risks caused by infection at site of implant placement be mitigated?

A
  • Ensure that infection has resolved prior to implant placement
  • Acute infection must be managed- consider RCT prior to extraction to reduce size of pathology and encourage healing
  • Get rid of infected teeth several weeks prior
34
Q

How can restorative status of adjacent teeth affect placement of implants?

A

Risk of recession with subgingival restoration margins on adjacent teeth

Risk of suboptimal aesthetics if trying to match a maxillary central incisor to a translucent, contralateral tooth with characterization

Also consider vitality, caries, perio

35
Q

How is restorative status of adjacent teeth categorised in terms of SAC?

A

Low risk- virgin teeth

High risk- restored

36
Q

What are the issues if the edentulous span is too narrow for implant?

A

Risk of damage to adjacent teeth

Risk of necrosis of bone between teeth and implants

Will have significant effect on ST aesthetics

37
Q

What are the issues if edentulous span is too wide for implants?

A

Challenge to fill place

Decision may be required on where to leave residual space

38
Q

How is length of edentulous span categorised as per SAC?

A

Low risk- one tooth > or equal to 7mm, one tooth > or equal to 5.5mm

Medium risk- one tooth <7mm, one tooth <5.5mm

High risk- 2 teeth or more

39
Q

How does bone at implant site alter risk of failure in dental implants?

A

Low risk- no deficiency

Medium risk- horizontal bone deficiency

High risk- vertical bone deficiency

40
Q

How does soft tissue at implant site alter risk of failure in implants?

A

Low risk- intact ST

High risk- ST defect

41
Q

What can help us evaluate the anatomy of implant site?

A

CBCT

42
Q

What are the relevant local anatomical features which could affect implant placement in maxilla?

A

Maxillary Sinus
Nasal Floor
Naso palatine canal
Infra-orbital nerve

43
Q

What are the relevant local anatomical features which could affect implant placement in mandible?

A

Inferior alveolar canal
Mental Foramen
Incisive canal
Lingual perforating vessels
Submandibular fossa

44
Q

What are the principles in prosthetically driven planning in implants?

A

Implants should be planned starting from the final planned prosthesis position (top-down planning)

This should be taken into account when requesting special tests

Prosthetic tooth position will dictate wheter an implant is possible in the correct 3d position

45
Q

What needs to be considered in 3D implant positioning?

A

Mesio-distal positioning
Mesio-distal orientation
Bucco-palatal positioning
Bucco-palatal orientation
Apico-coronal postioning

46
Q

What does 3D implant positioning depend on?

A

Implant system

Proposed gingival margin

Local anatomy

Prosthetic plan (cement v screw

47
Q

What must be considered in terms of mesio-distal orientation when placing implants?

A

Place safe distance from adjacent teeth (1.5mm on each side- not much margin for error)
-> Lowers risk of damage and bone necrosis which could result in ST defect between teeth/implants
-> May take radiographs halfway through treatment to check

*** If adjacent implants- must be 3mm apart

48
Q

What is the aim in terms of bucco-lingual positioning/orientation when placing implants?

A

Aim for 1mm of bone labially, >2mm of hard and soft tissue labially

49
Q

When may guided bone regeneration be considered?

A

Dehiscence

Fennestration

Inadequate contour

50
Q

In terms of apical-coronal position, how should implants be placed

A

Place implant 2mm apical to ACJ of adjacent tooth
-> Varies depending on implant system

51
Q

What are the different placement protocols for implants?

A

T1- immediate

T2- Early placement with soft tissue healing (4-6 weeks)

T3- Early placement with partial bone healing (12-16 weeks)

T4- Late placement in healed sites (6+months)

52
Q

What planning aids are used in implant treatment?

A

Study models- Mounted

Diagnostic wax up

Surgical template

Essex (provisional)

Clinical photographs

CBCT

Surgical Guide

53
Q

How is analogue planning of implants carried out?

A

Diagnostic wax ups can be utilized to plan the size and position of teeth to be replaced
-> Combined with CBCT information and knowledge of implant diameter to aid in planning

Can be transferred to mouth to demonstrate to patient aim of treatment

When agreed (and achievable!) can be converted to stone and surgical template made

54
Q

How is Digital planning of implants carried out?

A

Uses software to help identify relevant local anatomical structures and their proximity

Software will highlight potential issues with inter-implant spacing and orientation

Can be used to produce a surgical guide for implant placement
-> 3D printed
-> helps guide drilling

55
Q

What are the basic steps in placing a dental implant?

A
  1. Raise full thickness mucoperiosteal flap buccally and lingually
  2. Osteotomy- drill hole in bone (take radiograph after a few mm to check position)
  3. Once at length place implant
  4. Cover over with guided bone regeneration (collagen membrane)
  5. Suture
  6. Take post-op radiograph to ensure correct position

BDS4 Implant Symposium (2 decks)

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