immediate implants - dr harshavardhan patwal
TRANSCRIPT
IMMEDIATE IMMEDIATE IMPLANTS IMPLANTS
Dr Harhavardhan Patwal
•Rationale•Indications/Contraindications•Scientific Overview•Surgical Technique•Issues•Consensus Questions
IMMEDIATE IMPLANTS
6-12 months healing is recommended following tooth extractions prior to dental implant placement
Adell et al ,1981
Extraction of Teeth results in the loss of hard and soft tissues,a reduction of arch circumference and deficient width and heightof the residual ridge
Extraction of Teeth results in the loss of hard and soft tissues,a reduction of arch circumference and deficient width and heightof the residual ridge
Bone loss occurs both buccolingually and apicocoronally,with the first six months carrying the highest rate of resorptionin either direction.
Atwood,1983
Advantages of Immediate Implant Placement
•Reduction of Treatment Time•Minimization of Treatment Cost•Enhancement of Patient PsychologicalOutlook•Reduction of Surgical Procedure•Preservation of Ridge Contour•Enhanced Healing and Osteogenic potential•Simplification of Prosthesis•Optmization of aesthetic and functional results
• Traumatically Avulsed
•Residual Deciduous Teeth
•Horizontal/Vertical Fracture of Teeth
•Endo Failing
•Periodontally Compromised
•Non-Restorable Teeth
Indications
• Traumatically Avulsed
Indications
• Residual Deciduous Teeth
Indications
• Horizontal/Vertical Fracture of Teeth
Indications
• Endo Failing
Indications
• Periodontally Compromised
Indications
• Non-Restorable Teeth
Indications
• Inability to Develop Mechanical Stability
Width
Height
•Proximity to Adjacent teeth
•Placement outside alveolar envelop
•Presence of Infection
Contra-Indications
• Inability to Develop Mechanical Stability
Contra-Indications
• Proximity to Adjacent teeth
Contra-Indications
• Placement outside alveolar envelope
Contra-Indications
• Presence of Infection
Contra-Indications
•Sulcular Incisions with Vertical release•Atraumatic Extraction
Sectioning of Multi-root teethPeriotome
•Thorough Degranulation•Assessment of Socket Architecture•Widening/Deepening of Osteotomy•Placement of Implants•Placement of Graft/Membrane•Flap Closure
Surgical Technique
•Sulcular Incisions with Vertical Release
Surgical Technique
•Atraumatic Extraction
Surgical Technique
•Thorough Degranulation•Assessment of Socket Architecture
Surgical Technique
•Widening/Deepening of Osteotomy
Surgical Technique
•Placement of Implants
Surgical Technique
•Placement of Graft/Membrane
Surgical Technique
•Placement of Graft/Membrane
Surgical Technique
•Flap Closure
Surgical Technique
(Salama and Salama 1993)
• Dahlin-JOMI,89
•Lazzara-IJPRD,89
•Becker-JP,90
•Nyman-JOMI,90
•Schwartz-JOP,97
•Gilb-JOMI,93
•Wilson-JOMI,98
•Paolantonio-JP,01
•Cornelini-JOMI,00
•Becker-Perio-2000
ISSUES• Primary Stability•Thin Buccal Plate•Presence of Active Infection•Site- Posteriors?
Masticatory Forces
Bone DensityBone Volumes
1) Jumping Gap- What is the Threshold Gap Distance (HDD) b/n Implant & Bony Wall to warrant
use of Regenerative techniques?2) Loading - When is it advisable to load an
Immediate Implant (In view of limited Implant-Bony Contact).
(Immediate, Delayed Immediate, Conventional)3) Primary Stability Quantification-
If Early Loading is an Acceptable Protocol, what is the right measuring parameterfor Primary Stability.
Consensus Questions
Does the Gap Effects Osseointegration
Akimoto,Becker et al.JOP,1990 * Experimental
* Canine Model* 12 Weeks Study* End Points- Clinical Bone Fill
Histomorphometry*Control*Coronal Gap of 0.5mm*Coronal Gap of 0.975mm*Coronal Gap of 1.35mm
Ctrl- 400.5- 25.935- 121.35- 5
Apically No Difference Clinically/Histologically
Coronal 4 mmNo Statistical DifferenceNo Mobility Detected
“Gap Does Effect Osseointegration”
RESULTS
Clinical Bone Fill
Histomorphometrically(% BIC)
Bridging the GAPWarrer,L, Got Fredien,K et al. Clinical Oral Implant Research’91
•Experimental•Canine Model•Split Mouth•12 Weeks•Histological
Test Side Immediate Implant Covered with Membrane
Control Side No Membrane was used
Control Soft tissue facing coronal Portion of the Implant to varying degrees
Test Side Osseointegration was consistently observed
“Use of Membrane helps in Increased BIC”
RESULTS
Critical Gap Distance Wilson TG Jr,Buser,Cochran et al JOMI’98
Conventional II with HDD 1.5mm II with HDD 4.0mm
BIC72%60%17%
“HDD: 1.5-2mm is Critical for Osseointegration”
•Clinical•6 Months•Biopsy
Groups
Critical Maximum Gap Distance
Wilson TG Jr et al. JP,2003:74(3);402-409
Covered with CT Membrane
%age Bone-Implant Contact similar in all 3 Groups“HDD of 4 mm with membrane achieves Osseointegration”
•Clinical•6 Months•Biopsy
Conventional II with HDD 1.5-4 mm II with HDD> 4.0mm
Groups
Placement of Immediate Implant in Infected Sites
Novaes & NovaesIJOMI,1995
1st Report Chronic Peri-apical Infected sites
Novaes et al , IJOMI,1998
Experimental,Canine,HistologicalBIC is Higher in Non-Infected sites than in Infected sitesGrunder et al ,
IJOMI,1999,14:210-216
Clinical, Prospective,3 year StudyIncreased Implant Failure,if the tooth replaced was lost for Periodontal Infection
Placement of Immediate Implant in Infected Sites
Nir-hader, Orly et al.COIR,1998
Delayed Immediate Implant better option in Infected sites
Ivorio,Giovanni, Costigliola,G et al.COIR,12(4),2001
Clinical,Prospective,n=130N=36(Infected sites),3-5 year survival rateOverall Survival-97%Failure- 6 Implants(PA PD’itis)Survival rate-87%(In infected sites)
Immediate Loading of Immediate Implants
Ormiener et al COIR 2001,AugustMulticenter, Clinical ,Prospective,Randomized, N=546
“Immediate Loading / Immediate Implants is a predictable procedure”
10 implants failed out of 546
Lorenzi,M et al,2002Clinical, N=9 pat,Ant. Maxilla 50%-II,50%-Del.I
Periotest,RadiographsOut of centric contact, Occlusal Splint-8 weeksSuccess Rate- 96%
Factors for Early Loading of Immediate Implants
Kotsuyama,et al.Quintessence Dental Implantology,7(3)357-367:2000
•Sufficient Primary Stability
•Soft Tissue Healing(2-3) weeks
•Healthy Bone Quality(Density) - 400-450 HU(Cochran)
•‘Drilling Feeling’•Insertion Torque Mechanism•Radiographic•Transient Impact•Periotest•Resonance Frequency Analyzer
Primary Stability
•‘Drilling Feeling’ Trisi et al,COIR,1999
Good to distinguish between D-1 & D-4 BoneBut not between D-2 & D-3
•Insertion Torque Mechanism Friberg et al,COIR,1995Limited only to Self-Tapping Implants, A value of 45 Ncm has been advocated
•RadiographicCT Scan, Simplant 400-450 Hensefield Units
Sundan et al., COIR,1995:6;220-226
Reproducibility Standardisation Radiation,Time needed
Cochran,1998
Periotest
Caulier et al IJOMI,1997:12;380-386
Periotest gives Mechanical PropertiesOf Fibro-osseous Complex between Implant & Bone
Evans et al No Correlation between PTV & histologic BIC
Resonance Frequency Analyzer
Rassmussan,97,98,99
RFA Values, Histological Results & Removal TorqueValues show correlating results
Neil Meredith,AOO’01
Baseline-3 weeks ISQ Decreases3 Weeks-10 Weeks ISQ increases6 weeks-10 weeks No Statistical Difference
6 Weeks is Ideal Time to Load
Conclusions
•II have a high survival rate,between 93.9% to 100%•Implants to be placed 3-5 mm beyond apex for primary stability•Implants to be placed close to alveolar crest level (0-3mm)•Consensus regarding HDD filling still not conclusive•Membrane exposure is a question still unanswered•Absolute need for primary closure is still a question ?
Surgical Technique•Widening/Deepening of Osteotomy•Placement of Implants•Placement of Graft/Membrane•Flap Closure
• Inability to Develop Mechanical Stability
•Proximity to Adjacent teeth
•Placement outside alveolar envelop
•Presence of Infection
Contra-Indications
• Traumatically Avulsed
•Residual Deciduous Teeth
•Horizontal/Vertical Fracture of Teeth
•Endo Failing
•Periodontally Compromised
•Non-restorable Dental Caries
Indications
• Traumatically Avulsed
•Residual Deciduous Teeth
•Horizontal/Vertical Fracture of Teeth
•Endo Failing
•Periodontally Compromised
•Non-restorable Dental Caries
Indications
• Inability to Develop Mechanical Stability
•Proximity to Adjacent teeth
•Placement outside alveolar envelop
•Presence of Infection
Contra-Indications
• Inability to Develop Mechanical Stability
•Proximity to Adjacent teeth
•Placement outside alveolar envelop
•Presence of Infection
Contra-Indications
• Inability to Develop Mechanical Stability
•Proximity to Adjacent teeth
•Placement outside alveolar envelop
•Presence of Infection
Contra-Indications