revision Flashcards
four most frequently used parameters for assessing
success in implants:
(saq)
- Implant level
- Peri-implant soft tissue
- Prosthetic level
- Patient’s subjective evaluation (satisfaction)
How many complications a successful implant tx can have?
when a total of 4 or fewer complications (mild or moderate severity) are encountered
Implant Stability - Absence of mobility:
main determinants are:
- mechanical properties of bone tissue (influenced by healing)
- how well engaged the implant is with the bone (influenced by surgical technique)
A successful implant should have/not have the following sings and symptoms:
(saq)
● No persistent pain ● Bone loss less at 1st year <1.5mm ● No evidence of peri-implant radiolucency ● The implant should be immobile ● No persistent infection ● PPD < 3mm ● No suppuration should be present ● Absence of bleeding ● Absence of swelling ● Absence of recession The prosthesis is: ● Esthetically pleasing ● Functional ● No complications affecting the tx ● Absence of discomfort or paresthesia ● Patient should be able to chew comfortably
Intraoperative complications of implant placement:
hemorrhage nerve injury damage to adjacent teeth perforations ingestion or inhalation of components/instruments displacement of implant in sinus
severe hemorrhages are associated with:
incision of arteries
sinus lift procedures
preparation of the implant hole
damage to adjacent teeth:
associated with:
tx:
associated with:
excessive heat during surgery
inadequate distance b/w implant and tooth
wrong implant angulation
tx:
RCT
apicectomy
extraction
min distance b/w tooth and implant:
1.5-2 mm
displacement of implant inside sinus or nasal cavity:
caused by:
prevention:
(mcq)
caused by:
- inadequate primary stability
- thin maxillary bone
- suction effect and improper distribution of occlusal forces
- inadequate planning
- lack of experience
prevention:
- knowledge of anatomy
- correct pre-surgical planning
- post surgical follow up
early postoperative complication:
late postoperative complication:
(mcq)
early postoperative complication:
- mandible fracture
- flap dehiscence
- emphysema
late postoperative complication:
- failed osseointegration
- infections maxillary sinusitis
- peri-implantitis
- periapical implant lesions
- implant fractures
peri implant health =
peri implant disease =
peri implant mucositis =
peri implantitis =
(saq)
peri implant health = absence of suppuration, BoP, swelling and erythema
peri implant disease = inflammation around implants (either peri implant mucositis, peri implantitis)
peri implant mucositis = inflammation of mucosa
peri implantitis =inflammation affecting also the bone
- > bone loss, BoP
- > mobility is not an essential symptom
tx of peri-implant mucositis:
tx of peri-implantitis:
(saq)
tx of peri-implant mucositis:
- patient’s own self care - OH
- subgingival debridement
- mechanical cleaning and local irrigation
- mouthrinses
tx of peri-implantitis:
- > non-surgical treatment alone may not be effective
- should start with non-surgical treatment as first option and if the disease doesn’t resolve proceed with surgical treatment
- GBR and bone grafts
- non-surgical tx: local debridement, decontamination
- surgical tx: resection, reconstructive
- implant removal -> in cases where: failed osseointegration or mobile implant or suppuration
-> prevention is the best form of tx
Resective Therapy:
=
indication:
steps (peri-implantitis surgery):
= reducing/eliminating pathological peri-implant pockets, apical positioning of the mucosal flap, or recontouring of the bone with or without implantoplasty
indication:
presence of horizontal bone loss with exposed implant threads in non-aesthetic areas
steps:
a. Access
b. Removal of inflamed tissues
c. Decontamination
d. Performance of resective therapy
e. Apical positioning of the mucosal flap
indicators for peri-implantitis:
poor OH
history of periodontitis
smoking
types of implant placement:
- immediate placement
- early placement with soft tissue healing completed (4-8w)
- early placement with partial bone healing (12-16w)
- late/delayed placement with fully healed socket (6m)
immediate implant placement
=
requirements:
ADV:
DISADV:
(saq)
= implant placement in extraction socket at time of extraction
requirements:
- min bone loss on extracted tooth
- 3-5 mm bone beyond apex
- 3-4 bony walls remaining
ADV:
- reduced tx time
- reduced surgical procedures
- bone preservation
- gingival tissues preservation
- psychological advantages
DISADV:
- lack of control of final implant position
- inadequate soft tissue coverage
- difficult to obtain 1ry stability
- cost of bone graft
- inability to inspect all aspects of extraction site for defects or infection
bone grafts - examples:
“gold standard” bone graft is the:
(mcq)
- autografts (gold standard)
- allografts
- xenografts
- block grafts
- particulate grafts
-> autogenous bone graft resulted in the highest amount of newly formed bone in comparison to various bone substitutes
Limitations for augmentation in posterior mandible:
● Maxillary antagonist overeruption (too little space for prosthetic reconstruction)
● Covering a vertical graft while preserving depth of vestibule
2 stage procedure is preferred where:
mcq
implants are inserted about 4 months after the transplantation
Maxillary sinus augmentation:
= indications: contraindications: Success of the procedure depends on: grows more rapidly at what age? anatomy: lateral window is covered by:
(mcq)
(or antrum of Highmore)
= increases vertical bone height to allow placement of implants
/ = helps to increase the amount of bone in the requested region by lifting the Schneiderian membrane with/ without a bone graft to augment the region
-> it is the biggest pyramidal-shaped paranasal sinus
indications:
- Inadequate residual bone height
- Atrophic posterior maxillary alveolus
contraindications:
- Acute active sinus infection
- Recurrent chronic sinusitis
- Severe allergic rhinitis
- Neoplasm or large cyst of the sinus
- Previous sinus surgery like the Caldwell–Luc operation
- History of radiation therapy to maxilla
- Presence of Underwood’s septa/severe sinus floor convolutions
- Uncontrolled DB
- Alcoholic and heavy smoker
- Psychosis
grows more rapidly at what age?
-1 to 8y
roof: orbital floor
floor: alveolar process of the maxilla
- > primary dentition does not have an influence on its growth
- > total volume is smaller in completely or partially edentulous cases (than in dentate cases)
lateral window is covered by:
-a resorbable collagen membrane (to prevent ingrowth of fibrous tissue before the mucoperiosteum is readapted and sutured)
-> surgical intervention is recommended when the
height of the residual bone is < 6 mm
risk factors for peri-implantitis:
mcq
-periodontal disease
-smoking
-obesity
-excess cement cementation
-genetic and systemic conditions
-high doses of bisphosphonates
lack of maintenance
hyperglycemia
inadequate plaque control
mucositis
implant’s malposition
poorly designed prostheses
hormonal replacement therapy
Prior to maintenance of peri-implantitis, 10 points inspection:
- Plaque and calculus assessment
- Probing
- Bleeding or suppuration
- Recession
- Mobility
- Occlusion
- Contacts
- Percussion sensitivity
- Radiographic assessment
- Instrumentation
Maintenance:
Low risk:
Moderate risk:
High risk:
(mcq)
low risk:
- highly motivated
- excellent OH
- 1-2 implants
- no risk factors
moderate risk:
- loss of motivation
- fair OH
- 3-6 implants
- moderate smoker
- controlled medical issues
high risk:
- unmotivated
- poor OH
- previous periodontitis
- > 6 implants
- smokers more than half a pack
- poorly controlled systemic diseases
apicectomy:
indications:
contraindications:
complications:
includes:
objective:
criteria for diagnosis:
(saq)
indications:
- radiographic findings of apical periodontitis/ symptoms associated with an obstructed canal
- extruded material with clinical or x-ray findings
- RC floor perforation
contraindications:
- tooth has no function (unrestorable)
- inadequate perio support (perio compromised)
- vertical root fracture
- medically compromised patient
complications:
- adjacent anatomic structures damage
- excessive bleeding
- complications with the use of filling material
- incomplete root resection
- healing disturbances
- sensitivity
- trismus
- numbness
- puss
- postoperative pain/swelling
- fever
includes:
- incision and drainage
- closure of perforations
- root/tooth resections
objective:
-> surgically maintain a tooth that had an endo lesion and cannot be resolved by conventional endo tx or re-rct
criteria for diagnosis:
- fistula
- lack of sensitivity
- pain on palpation
- radiolucent air
- PDL thickening
cause of apical radiolucent lesion:
death of pulp with extension of infection periapically
cysts:
types:
common physical signs:
diagnostic tests:
tx:
types:
- epithelial
- odontogenic
- non-odontogenic - non-epithelial
- can cause mandibular fracture
- painful if the cyst becomes infected
common physical signs: • Swelling (intraoral or extraoral) • Displaced teeth • Mobile teeth • Eggshell crackling (crepitus) • Fluctuation
diagnostic tests:
x-rays
aspiration
incisional biopsy (if large cyst)
tx:
enucleation
marsupialization
which anesthesia to use for lesions:
LA
Vs
General Anesthesia:
LA - lesion involving a single tooth
GA - lesions in the posterior mandible and those covering > 2-3 teeth
enucleation:
Vs
marsupialization
= complications: Intra: Early: Late:
(mcq)
= cystECTOMY
-stripping away the cyst lining from the resorbed bony cavity, resulting in a hole which is filled with blood which becomes osteoid and then new bone
=cyctOSTOMY
- exposing the cyst lining and removing a small window from the lining and then suture
- > cavity can be packed with an antiseptic dressing
- > for large cysts
complications: intraoperative: -bleeding -fractured mandible -oroantral fistula -damage to adjacent teeth -nerve damage Early postoperative: Pain Swelling bruising, bleeding infection Late postoperative: recurrence
surgical drainage purpose:
saq
prevention of infection extension
relieve pain
relief from fever
improve general patient status
cellulitis
Vs
abscess
(saq)
= mixed aerobic and anaerobic bacteria cause infections
- go into deeper tissues and spread through CT
- early infections
= anaerobic bacteria predomination
- late chronic infections
- > pus generally spreads through the path of least R
4 stages of odontogenic infections:
saq
- first 3 days of symptoms: inoculation stage
- 3-5d: cellulitis
- 5-7d: abscess
- finally when abscess drains: resolution stage (healing and repair)
low severity infections:
moderate severity:
high severity infections:
(mcq)
low severity infections:
- involve vestibular and subcutaneous spaces
- low threatening potential
moderate severity infections:
- hinder access to airway
- causes trismus, swelling, elevate tongue
high severity infections:
- compress or deviate airway
- damage vital structures
-> Antibiotics alone may arrest but do not cure the infection
surgical goals to H&N cancer:
secure airway
establish drainage
remove cause of infection
incision and drainage:
decreases bacterial load
removal of infection cause:
eliminates substrate for continued bacterial growth
if failure to improve clinically then:
change current AB
hospital discharge:
saq
- no fever for 24h
- normal oral intake and excrete functions should be normal
- decreasing size of swelling and softening
- minimal wound discharge
principles for extraction:
saq
- good LA
- good visibility of surgical field
- no violence and force
- operation planning
The direction extraction force depends on according to the direction of the longitudinal axis of the root and proper sectioning the tooth
half impacted molar:
impacted molar covered by soft tissue:
impacted molar covered by bone:
easier than:
- impacted
- impacted molar covered by bone
- oblique backward and horizontal position (better be vertical)
degree of difficulty increases as:
depth increases
- > the deeper a tooth lies, the harder it is to access it
- > deeply positioned teeth are more likely to be near anatomical structures
- > so, the risk for surgical complications, elevates the complexity of the extraction process
what we can see on x-rays:
saq
- position and level of eruption
- relationship to M2
- root shape
- adjacent bone
- bone thickness
- nerve position
- cyst in the area
complications:
pre-operative:
post-operative:
pre-operative:
bleeding
post-operative:
edema
dry socket:
when it appears?
symptoms:
tx:
(saq)
when it appears?
3-4 days after patient’s extraction
symptoms:
- pain: dull, throbbing, moderate-severe
- foul odor or taste coming from the socket
tx:
-dressing in socket and replaced every 24h until symptoms subside
impacted teeth:
= most common impacted tooth: most common eruption time: best age for extraction: more complications seen in: lower complications seen in:
failed to erupt in expected position
- > lower impacted M3 are more frequent than upper ones
- > most common time frame for the eruption process is 18-24y
no rule what is the ideal age for extracting M3. It can be done at all ages
more complications:
older people
lower complications:
24y
-> But we usually expect the age of 18 where the root in most of them has grown beyond 2/3 of its length
endoscopy =
= transnasal removal of implant, management of perforating sinus membrane during the SFA
(removal of perforated implant from sinus)
All-on-4 Concept:
ADV:
DISADV:
(saq)
tx involves:
- single-unit full-arch fixed provisional prosthesis supported by 4 implants: 2 anterior upright and 2 tilted posterior implants, and is used with immediate loading
- > 45 degrees
- When used in the mandible, tilting of posterior implants makes it possible to achieve good bone anchorage w/o interfering with mental foramina
- In severely resorbed maxillae, tilted implants are an alternative to sinus floor augmentation
ADV:
- avoid anatomical structures
- allow longer implants anchored in better quality bone
- reduces posterior cantilever
- eliminates bone grafts in the endentulous maxilla and mandible
- high success rates
- implants well-spaced, good biomechanics, easier to clean
- immediate function and aesthetics
- final restoration can be fixed or removable
- reduced cost
DISADV:
-Free hand arbitrary surgical placement of implant is not always possible as implant placement is completely prosthetically driven
-Length of cantilever in the prosthesis cannot be extended beyond the limit
-It is very technique sensitive and requires elaborate pre-surgical preparation such as CAD/CAM, surgical splint
Indications for Single Tooth Implants:
mcq
- Trauma
- Endodontic failure
- Fracture
- Root resorption
- Anodontia
Combined peri-implantitis surgery steps:
a. Access
b. Removal of inflamed tissues
c. Decontamination
d. Implantoplasty
e. Grafting
f. Adequate flap adaptation
which are the most important parameters affecting success and are requirement for osseointegration?
Alveolar bone quantity, quality and density
sublingual space infection:
space contains:
important hallmark of this type of infection:
communicates with:
contains:
- sublingual gland
- lingual nerve
- sublingual artery and vein
- submandibular duct
important hallmark of this type of infection:
elevated tongue
communicates with:
submandibular space in the posterior aspects
Submandibular space infection:
can cause:
drainage with attention to avoid any surgical damage to:
can cause:
-trismus
drainage with attention to avoid any surgical damage to:
- submandibular gland
- facial artery
- lingual nerve
The signs and symptoms of infection are in Latin terms:
- dolor (pain)
- tumor (swelling)
- calor (warmth),
- rubor (erythema, redness), and
- functio laesa (loss of function)
Indications for removal impacted tooth:
- Pain, swelling, atypical symptoms
- Insufficient eruption space
- Damage to adjacent teeth
- They are partially erupted
types of surgical approaches for maxillary sinus floor augmentation:
- Maxillary sinus floor augmentation with the lateral
window technique
-> safe and predictable procedure
-> steps: LA, sinus exposed, incision, flap reflected, osteotomy - Osteotome-mediated sinus floor elevation
- Sinus membrane elevation w/o graft material
success of maxillary sinus floor augmentation depends on:
saq
● Hygienic and sterile environment ● Skill of the surgeon ● Use of NSAIDs and AB after surgery ● Uninfected and sterile graft ● Good surgical protocols
Maxillary sinus augmentation with graft placement simultaneous or delayed installation:
If primary implant stability is compromised,
then the implants are inserted after how long?
most common complication:
seen more frequently in:
(mcq)
indication:
- when bone height is < 6 mm
If primary implant stability is compromised,
then the implants are inserted after how long?
-4 to 12m after the augmentation procedure
- > cannot be placed simultaneously
- > final prosthetic solution is performed 3-6m after implant installation
most common complication:
perforation of Schneiderian membrane
- > presence of sinus septa and a residual bone height less than 3.5 mm increases the risk for a sinus membrane perforation
- > Other complications include bleeding, migration of implants into the maxillary sinus, postoperative infection, sinusitis, exposure of the graft, graft loss, oedema, seroma formation, benign paroxysmal positional vertigo and exposure of collagen membrane
seen more frequently in:
smokers
Maxillary sinus augmentation w/o graft and simultaneous installation:
most common complication:
most common complication:
perforation of sinus membrane
- > tx outcome seems not to be influenced by sinus membrane perforation, although implant loss has been reported in a case with a perforation of the sinus membrane
- > Other complications reported included postoperative infection, exposure of the covering membrane, swelling, mild postoperative oedema, pain, loosening of healing abutments and nose bleeding
- > bone density was significantly higher in sinuses augmented with a blood clot compared to an allogenic mineralized bone graft after 6 months
which technique to use for single implant placement of limited amount of bone regeneration is needed?
(mcq)
maxillary sinus elevation with lateral window technique w/o graft
Osteotome-mediated sinus floor elevation and simultaneous installation:
indication:
most common perforation:
when to be used (indication):
differences from maxillary sinus floor augmentation applying the lateral window technique:
(mcq)
indication:
-when residual vertical bone height is > 6 mm
most common perforation:
perforation of Schneiderian membrane
-> perforation of sinus membrane seems not to
influence the implant survival rate
Other complications include postoperative infection,
disorientated after surgery, nose bleeding, blocked nose, hematomas, benign paroxysmal positional vertigo and postoperative bleeding
-> is most suitable for installation of a single implant but can be used for multiple implants
differences from maxillary sinus floor augmentation applying the lateral window technique:
- less invasive
- time-consuming
- facilitates more vertical bone gain (than no graft tech)
overdenture:
hybrid:
fixed prosthesis:
(mcq)
overdenture:
- space denture increased
- high smile line
- lost lip support
hybrid:
- space denture lost
- low smile line
- conserved lip support
fixed prosthesis:
- space denture conserved
- low smile line
- conserved lip support
For tilted posterior implants, the distal screw access holes should be located at the occlusal face of which teeth?
(mcq)
P1
P2
or M1
If the implant supported prosthesis is opposed to RPD, CD or implant supported over-denture or a distal extension cast partial denture:
leave the most distal tooth slightly out of occlusion
