History and background What is an implant ? Why IMPLANTS..?

Case selection Pediatric considerations

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HISTORY AND BACKGROUND

 ANCIENT ERA - 1000 A.D

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Carved ivory tooth replacing the two missing incisors

the implantation of animal teeth

MEDIEVAL PERIOD (1000-1799 A.D)

Implants made from ivory, shells & bone were used. Allotransplantation (18 -19 Century) mainly in England & Colonial America. Albucasis de Condue ( 936- 1013 A.D) an Arab surgeon described the transplantation procedures . He attempted to use ox bone to replace missing teeth. In Japan in the 15th & 16th C. Wooden dowel & crown prosthesis was designed . The pin inserted into the root canal of non vital teeth. This was an early ENDODONTIC IMPLANT SUPPORTED
PROSTHESIS.

THE FOUNDATION PERIOD (18001910)

The endosseous oral implantology truly began in the 19th Century.

Maggilio in 1809 , a dentist at the university of Nancy

, France, author of the book called THE ART OF

THE DENTIST. The first reference to modern style

implants. He has described the implant & placement.

In 1886 Harris In 1889 Edmunds of New York reported on March 12 ,1889 to the First District dental society of that city. He implanted the metallic capsule.

Znamenski in 1891 reported on implantation made of

Porcelain, gutta-percha & rubber

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PREMODERN ERA ( 1910-1930)

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The first two decades of 20th C. predominated by the clinicians namely R.E Payne& E. J .Greenfield. R. E .Payne presented his technique of capsule implantation at the clinics of Third international Dental Congress, reported in the Dental Cosmos in 1901. Technique- Extracting the root , enlarging the socket with trephine, trial fitting of the capsule. He then placed grooves on both sides of the socket & filled 2/3rds with rubber, fitted the porcelain root into the capsule & set it with gutta-percha. In 1903 Sholl in Pennsylvania , implanted porcelain tooth with corrugated porcelain root.

 In 1913 Dr. Edward J. Greenfield came up with the surgical method to prepare osteotomy in the healed bone using trephine. He fabricated the hollow cylindrical basket root of 20 gauge iridioplatinum soldered with 24 carat gold. Precursor of hollow basket design

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 GREENFIELD EMPHASIZED ON The importance of intimate contact between bone & implant.

Hollow implants facilitated growth of bone into implant body &

secure it. 3 months period of unloading. Implants failures because of infection. His techniques were similar to present concepts of osteotomy

preparation, restoring after healing time

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 In 1920s Leger- Dorez developed expansible root implant, was comparable to a concrete expansion bolt. Smolon described the implant as a four part device with the shaft buried in bone with the internal threads to receive a screw , fastening the neck into the shaft. the post for attaching the prosthesis. The historical basis for the internal screws provided for the retention of prosthetic devices similar to todays implants. Tomkins 1925 implanted porcelain teeth. Brill in 1936 inserted rubber pins in artificially prepared sockets.

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THE DAWN OF THE MODERN ERA A.D

1935-1978

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Per-Ingvar Branemark

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titanium as an anchorage point. Concept of Osseo integration developed The first clinical trial was done in 1965. In 1971 surgical equipments.

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In May 1982 Dr. George Zarb organized the Toronto conference on osseointegration. Branemark presented Two stage threaded root form implant along with the 15 yrs research work & clinical trail.

Summary

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Before 1000 A.D tooth carved of stones , calcite, ivory were implanted. In the 1000 -1799 A.D mainly allotransplantation. In the 1800-1910 period beginning of root form endosseous implant of Au, Pt . In the 1910-1935 Greenfeild designed hollow basket implant. In 1935- 1978 Root form implants of the pin & screw type, Sub periosteal , Ramus blade, Ramus frame, Transosteal. In 1978 Branemark developed the Titanium implants, latter on different surface treated Ti implants developed.

COMPARISON OF FPDS ,RCTS AND IMPLANTS Mahmoud Torabinejad et al (J Prosthet Dent 2007;98:285-311)

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The 143 selected studies varied considerably in design, success definition, assessment methods, operator type, and sample size. Success rates for Implant supported prosthesis were higher than for RCTs and FPDs.

Long-term survival rates for Implant supported prosthesis and RCTs were similar and superior to those for FPDs.

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Creugers et al , Community Dent Oral Epidemiol 22 :448-452,1994.

Authors evaluated 42 reports since 1970 and concluded that 15 year survival rate of conventional fixed bridges is 74%.

Carl E Misch , DENTAL IMPLANT PROSTHETICS ON FPDS

Estimated life span for a FPD is 10 years.

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Abutment tooth caries is the most common cause of failure.

15% of all FPD abutments require endodontic treatment.

Failure of abutment teeth in a FPD is 8-12% at 10 years and 30% at 15 years.

Carl E Misch , DENTAL IMPLANT PROSTHETICS ON RPDS

Survival rate of 60% at 4 years. Survival rate of 35% at 10 years.

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Repair of abutment teeth 60% at 5 years and 80% at 10 years. Increased mobility , plaque, bleeding on probing and caries of abutment teeth.

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Abutment tooth loss of 44% within 10years.

Accelerated bone loss.

Removable prosthesis disadvantages :Carl E Misch

Bite force is decreased from 200psi to 50 psi.
Bite force of 15 year old denture wearer is reduced to 6 psi. Increased drug usage.

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IMPLANT SUCCESS RATE

Stephen L. Wheeler J Oral Maxillofac Surg. 2007;15:265.
200 implants of various designs were placed immediately into extraction sites. First group, the survival rate was 93.4%. Second group of implants had an 87.3% implant survival rate. Of 6 failures in the 1-stage group, 4 were directly related to a single patients failure to comply with postoperative instructions. When patient compliance was excluded a 98% success rate was reported

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MOY AND AGHALOO INT J ORAL MAXILLOFAC IMPLANTS ,22; 2007

95.5% survival for 1232 implants placed with GBR over a period of 12 to 72 months.

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Carl E Misch, DENTAL IMPLANT PROSTHETICS.

Many reports published since 1990 reported a survival rate from a range of 94.2% to 100% from a period of 1- 10 years.

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AND WE SHOULD NOT FORGET

GLOBAL TOURISM. COST OF DENTAL IMPLANT IN US IS 5-10 TIMES OF THAT IN INDIA. Avg. cost of Implant in US $3000.

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Def of Implant (GPT 8 )

Any object or material such as an alloplastic substance or other tissue, which is partially or completely inserted or grafted into the body for therapeutic, diagnostic, prosthetic or experimental purposes.
Def of Implantology Term historically conceived as the study or science of planning and restoring dental implants.

 Def of Dental Implant

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A prosthetic device made of alloplastic material implanted into the oral tissues beneath the mucosal or/ & periosteal layer &/or within the bone to provide retention & support for a fixed or removable dental prosthesis ;a substance that is placed into or / & upon the jaw bone to support a fixed or removable dental prosthesis. Def. Of Osseointegration The apparent direct attachment or connection of osseous tissue to an inert, alloplastic material without intervening connective tissue.

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CLASSIFICATION
Dental implants may be classified by type as
Endosseous, Subperiosteal,

Transosteal,
Intramucosal, Endodontic,

These implant types are subdivided as follows: Endosseous: Root form. Blade (plate) form. Ramus frame.

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Subperiosteal: Complete. Unilateral. Circumferential.

Transosteal: Staple. Single pin. Multiple pin.

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Indications for each implant type are specified below: ENDOSSEOUS, root form: o Adequate bone to support the implant with width and height being the primary dimensions of concern. o Maxillary and mandibular arch locations. o Completely or partially edentulous patients. ENDOSSEOUS, blade (plate) form: o Adequate bone to support the implant with width and length being the primary dimensions of concern. o Maxillary and mandibular arch locations. o Completely or partially edentulous patients.

 ENDOSSEOUS, ramus frame: oAdequate anterior bone to support the implant with width and height being the primary dimensions of concern. oMandibular arch location. oCompletely edentulous patients. SUBPERIOSTEAL, complete, unilateral, circumferential: oAtrophy of bone but with adequate bone to support the implant. oMaxillary and mandibular arch locations. oCompletely and partially edentulous patients. oStable bone for support.

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TRANSOSTEAL, staple, single pin, multiple pin: Adequate anterior bone to support the implant.

BRANEMARK SYSTEM COMPONENTS

FIXTURE pure titanium . The top -hexagonal design & threads .. The apical portion tapered with four vertical notches. COVER SCREW- seals the

coronal potion of fixture during the

interim period.
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ABUTMENT
Made of titanium in a cylinder shape. the apical portion has hexagonal shape to fit the coronal

portion of fixture.

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ABUTMENT SCREW insert through the abutment & threads into the fixture to connect the two components . GOLD CYLINDER- made of lAu , Pl, Pd. It is machined to fit the coronal portion of the abutment. It becomes integral part of final prosthesis. GOLD SCREW inserted through the gold cylinder & threads into the abutment screw to connect the gold cylinder & abutment.

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For long-term successful performance of all dental implant types the following general factors should be considered: Biomaterials. Biomechanics. Dental evaluation. Medical evaluation. Surgical requirements. Healing processes. Prosthodontics. Postinsertion maintenance.

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Chief Complaint
The reason the patient is seeking treatment His desires, expectations

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History of Presenting Illness

The etiologic factors which contributed to the present situation of teeth,bone and soft tissues should be evaluated It gives an idea of oral health status of patient

Past Dental Problems

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The dental treatment taken in the past and their outcome Time elapsed since extraction and if extraction was eventful

Medical history
Medical evaluation remains of paramount importance in implant dentistry It includes
A Medical Evaluation Form
To review patients systemic health and medications

Vital Signs

BP , pulse , respiration , temperature ,

Laboratory Tests
Complete blood picture , urine analysis , bleeding time, clotting time ,prothrombin time blood sugar , biochemical test, ECG etc

CONTRAINDICATIONS TO IMPLANT TREATMENT

Absolute Contraindications are

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Recent MI Valvular prosthesis Severe renal disorder Treatment resistant diabetes Osteodestructive disease Radiotherapy in progress Regional malignancy Psychosis Blood dyscrasias

Relative contraindications Prolonged use of cortico steroids Smoking habit Chemotherapy in progress Mild liver or kidney disease Minor endocrinopathy Cardiovascular disease Connective tissue disorder Drug or Alcohol abuse

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DIAGNOSTIC METHODS
Clinical examination
Should consist of complete routine soft and hard tissue examination Extraction sites should be evaluated for complete healing In addition following should be evaluated

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Existing occlusion

Existing occlusion should be evaluated as it determines the occlusal forces directed to the implant Any prematurities present need to be corrected
Existing plane of occlusion

A proper curve of Spee and Wilson are indicated for proper esthetics And to prevent posterior lateral interference during excursion

 Interarch space Ideal interach space for fixed prosthesis is 7mm in posterior region 8mm in anterior region For removable prosthesis 12mm

Existing OVD

It is often decreased in completely or partially edentulous patients If it needs to be restored , it should be done before implant placement

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Maxillary anterior tooth position If not satisfactory should be corrected As it plays an important role in overall treatment plan Maxillo mandibular arch relationship Improper skeletal relationship can be modified by orthodontic or orthognathic surgery In long term edentulous patients pseudo class III is often seen This requires proper positioning of the implant for esthetic results

 Missing teeth locations and number

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Helps to determine the number and position of implants to be placed

TMJ
No abnormal signs or symptoms should be present Normal mouth opening

 Arch form Three forms square ,tapering ,ovoid Tapering arch form requires greater number and width of implant Soft tissue assessment Soft tissue at the implant site should be well keratinized Thickness of 2-3 mm , thickness greater than this requires reduction.

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Existing Prosthesis

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Evaluate esthetic, phonetics , position of teeth ,VD

Lip line
Resting lip position Maxillary high lip line during broad smile Mandibular low lip line during speech Influences treatment planning specially in anterior region

Natural teeth to be used as abutment

Mobility if mobile should not be splinted to implant Crown height Crown root ratio ideal crown root ratio is 1 : 2 Position no tipping , rotation , extrusion should be present Endodontic and periodontal status Caries Root configuration and root surface area

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Soft Tissue Attachments

Mandibular Movements

Evaluation of Stress Factors

Parafunction Masticatory dynamics

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Opposing arch
Position of implant abutment

Arch length
Arch length should be evaluated as it will determine the no of implants that can be placed It should be kept in mind that
2 implants should be separated by 3mm Implant and natural teeth by 1.5mm

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Manual Palpation
With thumb and fingers
A sharpened periodontal probe Ridge or bone mapping can be done using
Two dimensional slide caliper method Bone caliper or sharpened boleys gauge

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IMPLANTS IN PEDIATRIC PATIENTS???

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Indications
Hereditary Anhidrotic ectodermal
Dysplasia (HAED) Alveolar Clefts Trauma Tumor Resection

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Contraindications Childs inability to perform oral

hygiene Presence of adjacent primary teeth Inadequate quantity or quality of bone Unrealistic parental expectations

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Pediatric Patient Classification

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Group 1: Missing a single permanent tooth

Ideally, placement should be delayed until completion of alveolar development and eruption of all permanent teeth Implants placed early in alveolar growth may become submerged, requiring a longer prosthesis and compromising implant success

Pediatric Patient Classification

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Group 2: Oligodontia (as in HAED)

Alveolar process demonstrates abnormal growth, and incidence of submerged implant is low Placement should begin as soon as patient understands treatment and can perform maintenance

Pediatric Patient Classification

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Group 3:Acquired anodontia due to tumor resection or trauma reconstructed with bone Graft
No concerns regarding alveolar growth

Implants placed as soon as appropriate from psychosocial standpoint

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3. 4. 5.

6.
7. 8.

Carl E Misch: Contemporary Implant Dentistry 68 Georg Watzek : Endosseous Implant Scientific And Clinical Aspects Babbush : Dental Implants Principles And Practice Charles M Weiss : Principles And Practice Of Implant Dentistry Branemark ,Zarb,Albrektsson : Tissue Integration In Clinical Dentistry Philip Worthington, Brien R Long, William E Lavelle : Osseointegration In Dentistry Phillips : Science Of Dental Materials ,eleventh edition Craig And Powers : Restorative Dental Materials

 Westwood, RM, Ducan, JM. Implants in adolescents: A 69 literature review and case reports. Int J Oral Maxillofac Implants 1996;11:750-755. Brugnolo E, Mazzocco C, Cordioli G, Majzoub Z. Clinical and radiographic findings following placement of singletooth implants in young patients-case reports. Int J Perio Rest Dent 1996;16:5421-433. Cronin RJ, Oesterle LJ, Ranly DM. Mandibular implants and the growing patient. Int J Oral Maxillofac Implants 1994;9:55-62.