Level II: Advanced Implant Placement and Restoration

Course

Dr. David DaliseDr. Gary McCabe Ross

Diagnosis and Treatment Planning

Treatment Planning

• Patient’s desire must be determined – Fixed or Removable

• Comprehensive Stomatognathic Assessment

Comprehensive Stomatognathic Assessment (continued)

• Health history• Radiographic Assessment

– Intraoral survey for dentulous patients– Extra Oral for edentulous patients

• Tomographic (Cone Beam)• Panoramic

Hard Tissue Evaluation

• Ridge Classifications• Ridge Angulation• Bone Density or Type

Partially Edentulous Arch with Bilateral Edentulous Areas Posterior to Remaining

Natural Teeth

Partially Edentulous Arch with Bilateral Edentulous Areas Posterior to Remaining

Natural Teeth

Partially Edentulous Arch with Bilateral Edentulous Areas Posterior to Remaining

Natural Teeth

Partially Edentulous Arch with Bilateral Edentulous Areas Posterior to Remaining

Natural Teeth

Partially Edentulous Arch with Bilateral Edentulous Areas Posterior to Remaining

Natural Teeth

Partially Edentulous Arch with Unilateral Edentulous Area Posterior to

Remaining Teeth

Partially Edentulous Arch with Unilateral Edentulous Area Posterior to

Remaining Teeth

Partially Edentulous Arch with Unilateral Edentulous Area with Natural Teeth Remaining Anterior and

Posterior

Partially Edentulous Arch with Unilateral Edentulous Area Anterior to Remaining Natural Teeth, and

Crosses the Midline

Classification of Completely Edentulous Arches

Classification of Completely Edentulous Arches

Classification of Completely Edentulous Arches

Classification of Completely Edentulous Arches

Classification of Completely Edentulous Arches

Classification of Completely Edentulous Arches

Classification of Completely Edentulous Arches

Classification of Completely Edentulous Arches

Classification of Completely Edentulous Arches

Classification of Completely Edentulous Arches

Classification of Completely Edentulous Arches

Classification of Completely Edentulous Arches

Soft Tissue Evaluation

• Attached/Keratinized Gingival Tissue

• Unattached/ non-Keratinized Mucosal Tissue

Occlussal Analysis

• Jaw relationship/Occlussal classification- Class I- Class II- Class II- Crossbite- Interarch vertical dimension

Occlussal Analysis

• Parafunctional analysis– Bruxism– Clenching– Tongue Thrust– Occupational Hazards

Systemic Disease

• Diabetic• Autoimmune diseases• Chemotherapy• Immunosuppressed • Bisphosphonates

Prosthetic Analysis

• Fixed

• Removable– Overdenture– Hybrid

Implant Placement

Root Form Implants

• Straight, Non-tapered body

Root Form Implants

• Tapered Body

Root Form Implants

• One-Piece Implants

Root Form Implants

• Short Implants – < 8mm

“Mini” Implants

– Less than or equal to 3.0mm

1.8mm

3.0mm I-Mini

Anatomical Considerations

• Mandible– Anterior: Anterior to the mental foramen

• Anatomical considerations– Angulation of alveolar process relative to occlusal/incisal plane

of planned prosthetics.– Buccal/lingual width of alveolar ridge.– Vertical height of alveolar ridge.

• Bone density– Class D1,D2, D3, or D4– Usually type D1 or D2

Note: Anterior mandible has the highest incidence of initial implant failure due to over heating of bone during osteotomy procedure. Use caution and adequate irrigation to minimize heat production during osteotomy!

Anatomical Considerations

– Posterior: distal to the mental foramen• Anatomical considerations• Lingual concavity• Location of inferior alveolar canal• Location of the mental foramen• Variation of buccal to lingual alveolar bone

height

Note: Bone quality in this region is usually type D2 or type D3. Rarely type D1, but possible type D4.

Anatomical Considerations• Lekholm and Zarb’s four

bone qualities for the anterior region of the jaws:– Quality 1: Composed of

homogenous compact bone

– Quality 2: Thick layer of cortical bone surrounding dense trabecular bone.

– Quality 3: Thin layer of cortical bone surrounded by dense trabecular bone of favorable strength.

– Quality 4: Thin layer of cortical bone surrounding a core of low-density trabecular bone.

D1

D2

D3

D4

Maxilla

• Anterior (pre maxilla): anterior to the maxillary sinus– Radiographic landmarks

• Anterior border of maxillary sinus• Nasal Antrum/Spine• Anterior Palatal Foramen (incisive)• Canine Eminence/ Fossae

Maxilla

• Posterior: distal to anterior border of the maxillary sinus extending to maxillary tuberosity.

– Radiographic landmarks• Posterior border/ wall of the sinus• Medial wall of sinus• Floor of sinus• Tuberosity • Anomalies

– Webbing– Mucoseals– Polyps– Cysts– Thickened sinus membrane– Tumors (pathologic or benign lesions)

Posterior: distal to anterior border of the maxillary sinus extending to maxillary tuberosity.

Note: When reading tomograph, must be able to confirm patency of maxillary sinus ostium prior to contemplating any future sinus grafts.

Surgical Considerations

• Access Assessment– This is critical in determining the ability

to place implants, both literally and in proper inclination for final prosthetic outcome. In basic terms, is there enough room to perform the osteotomy procedure and place the implant in an ideal/acceptable position. If not, this must be determined prior to final case design.

Surgical Considerations

• Flap– Indications/Advantages

• Unacceptable osseous contours requiring osteotomy or osteoplasty prior to implant placement.

• Inadequate zone of attached/keratinized tissue in area of planned implant/abutment tissue interface.

• Allows direct visual assessment of osseous contours in planned site for implant placement.

• Required for two stage implant placement.• May be advantageous if there are concerns about

bacterial contamination of implant/osseous interface. • Allows for primary closure over osteotomy

Flap (continued)

– Design• Considerations for proper access to osteotomy site• Allows for tension free flap reflection• Consideration for maintenance of proper gingival architecture, especially

maintenance of interdental papillae.• Esthetic zone• Biotype considerations

– Thick or thin

– Closure• Primary – tension free to prevent secondary opening of suture line which is

most common post operative complication.– Release of Tissue

• Prevents tension on flap closure• Confirmation of adequate release should be confirmed prior to placement of

grafts and/or implants, not after placement. Failure to do so may result in inability to attain primary closure over graft/implant site resulting in failure do to lack of primary closure of suture line.

– Anatomical considerations• Neurological• Vascular• Boney (Osseous)

Flap, Anatomical Considerations (continued)

• Neurological – Be aware of location of nerve bundles prior to incisions for flap release.

– i.e.: Location of the mental foramen, incisive foramen, infraorbital foramen, lingual branch inferior alveolar nerve, and posterior palatal nerve.

• Vascular– Must know location of vascular bundles prior to initiation of incision for flap. i.e.:

Facial artery, lingual artery, incisive canal, mental artery, palatal artery.• Boney (Osseous)

– Location of prominent boney eminences and relationship to proper flap design. i.e.: Canine eminence, anterior nasal spine, maxillary tuberosity, retro molar pad.

• Muscular– Frenum attachments– Massetter muscle– Pterygoid muscles– Labialis muscles/obiquilaris-oris

• Glandular– Need to pay attention to the sublingual salivary glands.– Need to pay attention to the salivary ducts.

» Sublingual» Parotid gland/duct

Single Tooth Esthetic Zone (preop)

Incisal View

Single Tooth Esthetic Zone (preop)

Labial View

Papillae Saving Incision

Extension to Lingual

Tissue Flap Release

Flap Release Continued

Initiation of OsteotomyUtilizing Osteotomes

Implant Placed with Cover Screw

Primary Closure

Flapless Surgery

– Indications/Advantages• Well documented, adequate bone height and width.• Adequate zone of attached keratinized tissue.• Reduced surgical time• Reduced post operative healing sequelae• Less perceived trauma by the patient.• Increases patient acceptance of procedures.

– Determining location of osteotomy• Site should be predetermined with diagnostic wax up

and/or surgical stent.• Occlusal loading and force vectors ultimately

determine location of implant osteotomy.• Root angulation and proximity of existing teeth must

be considered.• Anterior or Posterior esthetic or non esthetic zone.

– Biotype of tissue

Flapless Surgery

– Methodology• Anesthetize patient appropriately for procedure

– Infiltration or Nerve Block as indicated• Place surgical guide

– This should be stabilized either by existing dentition or on non-mobile anatomical bone supported tissues

• Mark the tissue with either dye or surgical probe to produce bleeding point or with pilot drill.

• Pilot hole/Tissue Punch/Guide Pin– Sequence can vary according to circumstance

• Initial osteotomy/pilot hole• Check alignment/insertion angle with guide pin

– Visual– Radiographic

• Finish osteotomy• Implant Placement

– Torque to appropriate levels» Maxillary – 20 N/Cm minimum» Mandibular – 30 N/Cm minimum

• Temporize as indicated– Armementarium

Flapless Surgery

– Armamentarium• Surgical Stent• Implant Surgical Kit• Appropriate Tissue Marking Implements

– I.E. Denture marking stick, probe, or tissue punch

• Tissue Punch– Rotary– Disposable

• High speed handpiece with irrigation• #8 Round Bur

Case Example # 2Pre Operative

Pre Operative Ridge

Pre Operative RidgeOcclusal View

Acrylic Stent in Place

Marking Ridge Utilizing Acrylic Stent

Marking Ridge Utilizing Acrylic Stent

Osteotomy Sites Marked On Ridge

Tissue Punch Pre Osteotomy

Appearance of Ridge Following Initial Use of Tissue Punch

Removal of Tissue Plug and Initiation of Pilot Hole (#8 Bur)

Appearance of Ridge Following Removal of Tissue Plug

Appearance of Ridge Following Removal of Tissue Plug

Pilot Drill – Initial Osteotomy

Flapped to Expose Bone Fixation Screws for Removal Prior to Implant Placement

Bone Fixation Screw

Occlusal View

Removal of Fixation Screw

Ligated Paralleling Pin

Ligated Paralleling Pins

Implant Placement with Handpiece

Implant Placement with Handpiece

Implant Placement with Handpiece

Implant Placement with Handpiece

Implant Placement with HandpieceImplant Seated to Proper Depth

Implant Placement with HandpieceImplant Seated to Proper Depth

Implant Placement Prior to Soft Tissue Closure

Placement of Healing Abutments/Temporary Abutments

Occlusal View

Flap Closure

Flap Closure

Flap Closure

Final Occlusal View

Temporary Abutments Prepared for Use with Temporaries

Temporary Stent in Place Over Implants

Finalizing Reduction of Temporary Abutments

Obturation of Abutment Access

Use of Tempit Light Cure to Close Access Hole

Prefabricated Silicone Temporary Stent

Temporary Stent with BIS-Acrylic Temporary Material in Place

Immediate Post Operative Temporization

Osteotomies

• Mark intended location of entry point

• Pilot hole• Alignment verification• Tissue Punch if flapless• Completion

– Rotary (excavation)• Use of rotary osteotomy drills

– Osteotomes (condensation)• Expansion of bone• Slow sequential increase in size of

osteotome• Final size of osteotome determined

by bone type/density– I.E. D1, D2, D3, and D4

Implant Placement

• Delivery to osteotomy– Hand Placement – Rotary Handpiece Placement

• Seating to final depth– Assure alignment buccal lingually if implant is

contoured– Verify proper depth of implant/abutment

platform relative to proper tissue emergence profile

• Verification of proper placement– Clinical appearance– Radiographic

Implant Placement

• Revisions– Realignment of osteotomy

• Correct as early as possible. Pilot hole and alignment check should be first indication that osteotomy needs correction.

– Removal of implant• Remove implant immediately if there are indications that

implant may cause problems with existing teeth or neurologic/vascular bundles.

– Salvaging a problematic implant placement• Oversize implants

– Reserved only to salvage inadvertent oversized osteotomy• Revising the depth of the osteotomy

– Remove implant– Revise osteotomy to proper depth– Replace implant

Immediate Post Placement Options

• Two-stage option– Place cover screw and close it; flap was

utilized– Flapless option. Place cover screw and

allow to close by secondary intention.• This option would be used if conditions allow

for flapless surgery; however, no inadvertent loading of implants is desired.

Immediate Post Placement Options

• One stage option– Place healing abutment

• Select proper height– Healing abutment should protrude at least to the level of tissue

• Adaptation to prosthetics– Modification of Healing Abutments or Temporary Abutments to

allow for placement of temporaries.

– Place Restorative Abutment• Select proper abutment type

– Cementable prosthesis» Generally most preferable and least problematic for crown

and bridge applications– Screw retained prosthesis

» For use in situations with limited or inadequate abutment height for adequate retention of prosthesis or for splinted bar type overdenture prosthetics.

One Piece Implants

• Why?– Strongest– Eliminate abutment/implant interface

• Initial bone loss/saucerization– Simplify temporization– Simplify prosthetic procedures– Lowest cost

• When?– Ability to place implant in the ideal circumstances

• Ideal inclination of implant and abutment relative to existing dentition or planned prosthetic design.

– No contraindicated pre existing parafunction• Bruxism• Tongue thrust• Cross bite• Unusual lateral forces on implant/abutment

• Where– Anterior or posterior when appropriate– Highly dependent on desired anticipated outcomes

One Piece Implants

• Temporization options– Adaptation to pre existing prosthetics

• Implant must be determined to be stable enough to accept immediate load if this option is selected.

– Fabrication of new temporaries• Prefabricated

– ION type crown forms modified with appropriate liner to adapt to margin of implant/abutment.

• Immediate, in the mouth fabrication– Pre made silicone mold fabricated from diagnostic wax up.

– Use of pre extraction/implant site impression (elastomeric type)

Implant Loading

• Considerations– Immediate Loading

• Why?– Improves patient acceptance/satisfaction with

implant procedures due to immediate gratification and perceivable results.

– May improve hard and soft tissue responses and esthetics in critical zones.

– Can usually justify a higher fee in accordance with acceptance of higher risk of failure by both practitioner and patient.

Implant LoadingImmediate Loading

• When?– When conditions exist that allow for idealized

immediate stabilization of implant with minimal contraindications predisposing the implant to failure.

• How?– Implant must be stabilize with an immediate

loading torque of not less than 40 N/Cm and ideally up to 55 N/Cm.

– Temporary must be placed with no lateral occlusal/parafunctional forces.

Delayed Loading

• Why?– Still considered most predictable standard of

care.– Minimizes or eliminates detrimental functional

stresses on implants during integration phase.– No immediate availability of temporary or final

prosthetic solution.

• Where?– Any place that is contraindicated for

immediate loading.

THANK YOU

Questions?