contents

• History and background

• What is an implant ?

• Why IMPLANTS…..?

• Case selection

• Pediatric considerations

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HISTORY AND BACKGROUND

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ANCIENT ERA - 1000 A.D

Carved ivory tooth replacing the two missing incisors

the implantation of animal teeth

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MEDIEVAL PERIOD (1000-1799 A.D)

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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.

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THE FOUNDATION PERIOD (1800- 1910)

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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.

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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.

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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 today’s implants.

Tomkin’s 1925 implanted porcelain teeth.

Brill in 1936 inserted rubber pins in artificially prepared sockets.

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THE DAWN OF THE MODERN ERA 1935-1978 A.D

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Per-Ingvar Branemark

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

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Summary

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.

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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.

22COMPARISON OF FPDS ,RCTS AND IMPLANTSMahmoud Torabinejad et al (J Prosthet Dent 2007;98:285-311)

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%.

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Carl E Misch , DENTAL IMPLANT PROSTHETICS ON FPDS

Estimated life span for a FPD is 10 years.

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.

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Carl E Misch , DENTAL IMPLANT PROSTHETICS ON RPDS

Survival rate of 60% at 4 years.

Survival rate of 35% at 10 years.

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.

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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 patient’s 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.

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Def of Dental Implant

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 OsseointegrationThe apparent direct attachment or connection of osseous

tissue to an inert, alloplastic material without intervening connective tissue.

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Dental implants may be classified by type as

• Endosseous,

• Subperiosteal,

• Transosteal,

• Intramucosal,

• Endodontic,

CLASSIFICATION34

These implant types are subdivided as follows:

· Endosseous:         Root form.         Blade (plate) form.         Ramus frame.

· 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.

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• 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: o Adequate anterior bone to support the implant.

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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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CASE SELECTION

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

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

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Past Dental Problems The dental treatment taken in the past and their outcomeTime 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

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CONTRAINDICATIONS TO IMPLANT TREATMENT

Absolute Contraindications are Recent MI Valvular prosthesis Severe renal disorder Treatment resistant diabetes Osteodestructive disease Radiotherapy in progressRegional malignancy Psychosis Blood dyscrasias

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Relative contraindications Prolonged use of cortico steroids Smoking habit Chemotherapy in progressMild liver or kidney disease Minor endocrinopathyCardiovascular 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

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Interarch space Ideal interach space for fixed prosthesis is 7mm in posterior region 8mm in anterior regionFor 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 correctedAs 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

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Missing teeth locations and number

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

TMJ

No abnormal signs or symptoms should be present Normal mouth opening

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Arch formThree forms square ,tapering ,ovoid Tapering arch form requires greater number and width of implant

Soft tissue assessmentSoft 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 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

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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 CariesRoot configuration and root surface area

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Soft Tissue Attachments

Mandibular Movements

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Evaluation of Stress Factors

Parafunction

Masticatory dynamics

Opposing arch

Position of implant abutment

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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

• Child’s 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

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

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Pediatric Patient Classification

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

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Pediatric Patient Classification

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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1. Carl E Misch: Contemporary Implant Dentistry 2. Georg Watzek : Endosseous Implant – Scientific And

Clinical Aspects3. Babbush : Dental Implants – Principles And Practice4. Charles M Weiss : Principles And Practice Of Implant

Dentistry 5. Branemark ,Zarb,Albrektsson : Tissue Integration In

Clinical Dentistry 6. Philip Worthington, Brien R Long, William E Lavelle :

Osseointegration In Dentistry7. Phillips : Science Of Dental Materials ,eleventh edition8. Craig And Powers : Restorative Dental Materials

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Westwood, RM, Ducan, JM. Implants in adolescents: A 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 single-tooth 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.

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