surgical principles i - geauxperio course presentations... · 2017-05-03 · • silverstein lh....
TRANSCRIPT
FirststageSurgicalprinciples
TheodorosKatsarosLSUPeriodontics
8/26/2014
SurgicalPrinciples• Flapmanagement
• Implantplacement
• Sutures
• Implantstability
• Antibiotics
Lekholm &Zarb
Misch
Misch BoneDensityClassification
• Atraumaticbonepreparation• Closeapproximationoflivingbonetoimplantsurface
• Absenceofmovementattheinterfaceduringhealing(lessthan100-150μm)
D1bone
• minimalreflectionbecauseoflessbloodsupply
• completeclosure• shouldminimizeheat• 80%BIC• 1minbw osteotomiestocooldown• highestspeedlowesttemps
D2bone
• 2500rpmdrillspeed• Drillcontactlessthan5every10sec• Bonetapwhenimplantengageslateralorapicalcorticalboneat30rpm
• Implantmaybeinsertedwithtorqueupto75N-cm
• BIC70%• 4monthsbeforerestoration
D3bone• 375-750Hountsfield Units• Drilltimelessthan10sec• Largerdiameterimplants(5,6mm)inthemolarregions
• Preparedtoavoidundesiredcorticalperforations,firmhandthatpreventslateraldisplacementofimplants
• Notappingespeciallywithhandratchet• BIC50%• 5monthshealingbeforerestoration
D4bone• BICafterinitialplacementlessthan
25%• Lessthan375HU• Bonecompactioninstrumentsare
indicatedafterthepilotdrills• Handwrenchiscontraindicated• Implantshouldbeplacedbelowthe
bonelevelifanyriskofloadingisexpected
• Reportsintheliteraturethatitassociatedwithincreasedriskofsurgicalfailures
• Extendedhealingtime(6months)
SurgicalProcedure
• Two-stagesurgery
• One-stagesurgery
• Direct,one-stagesurgery
Two-stagesurgery• Directvisionofcrestalbone• Abilitytobonegraftthesiteifneeded• Implantisplacedatorslightlybelowthecrest• Localhygieneoranaerobicbacteriaarenotcriticalduringinitialhealing
• Crestalandfacialregioncanbere-evaluatedduringuncovery
Two-stagesurgery
• Objectives– Exposetheimplantwithoutdamagingthesurroundingbone
– Controlthethicknessofsofttissuessurroundingtheimplant
– Facilitateoralhygiene– Ensureproperabutmentseating– Preservesofttissueesthetics
One-stagesurgery
• Theimplantisplacedslightlyabovethebonecrestandsofttissuesareplacedaroundthehealingabutment(easiertorestore,lesscrestalboneresorption,betterhemidesmosome connectionobserved)
• Allowssofttissuestohealatthesametimewithboneinterface
• Noneedfora2nd surgery
One-stagesurgery
• Lessindicatedwhenbonegraftisneeded• AmountofKGshouldbeadequatetorepositionatleast1.5mmtothefacialaspectofthehealingabutment
• Increasedriskofloading• Estheticsmaybeaconcern
DirectOne-stageSurgery• Minimaltrauma(lessswelling,pain,discomfort,nosutures)
• Provideestheticsofttissueresults• Shouldonlybeusedwhenbonewidthis>8mm• KGshouldbeadequate• Difficulttoseethelineonthedrills• Difficultyinassessingtheimplantcrestmoduleinrelationtothebonelevel
Placementmethod(one- ortwo-stage)doesnotseemtoaffectosseointegration.Thedifferencesthatmayobservedmaybeattributedtoimplantdesigncharacteristics.
Boioli etal2001
Surgicalprocedure
• 1.5mmdistancefromimplanttotooth(6.5mmbetweenCEJofeachtoothminimum)
• Crestalincisionextendedthroughinterproximalandsulculartissuesoftheadjacentteeth
• Atleast1.5mmofKGshouldbeleftonthebuccaloftheincisionline
• Osteotomystartswith roundburand2mmendcuttingstarterdrill
• Preferredspeedat2500rpm
Surgicalprocedure• Afterinitialosteotomyitisassessedforproperposition
• Linderman bur(side-cutting)canbeusedtocorrectitifneeded
• Implantshouldbeatleast1.5mmfromadjacentteethand1.5mmfromtheoutercrestalcorticalplates
Surgicalprocedure
• Thresholdtemperatureforimpairedregenerationofboneis44-47o C
Surgicalprocedure
• Criticalfactorstominimizeheatduringosteotomypreparation:– Coolingfluid– Bonequality– Minimumvolumeofboneremovedbyeachdrill– Frequency/timeofcontact– Depth– Pressure– Speed
Surgicalprocedure• Radiographensuresproper
angulationandposition• Atleast2mmfrommandibular
canaland0.5mmfrommaxillarysinusand5mmfrommentalforamina
• Whenpossibleosteotomyshouldbe1-2mmmorethanimplantlength
• Bonetaporthreadformerat30rpm,irrigationisbeneficialduringthistechnique
• Osteotomyisthenlavaged andaspirated
Surgicalprocedure
• Implantshouldnotrequiremorethan35N-cmtobeplacedtoavoidcompressionnecrosis
• Post-insertionPAistakenwithimplantinitsfinalposition
• Coverscreworhealingabutmentcanbeslightlytightened,loosenedandtightenedagainandimplantshouldnotrotateduringthisprocedure
• Implantplacementmaybeabortedatanytimeoftheprocedure!
Surgicalprocedure
Insertiontorqueof32Ncm improvesimplantprognosis
Ottoni etal,2005
Favorableclinicalresultscanbeachievedwitha25 Ncm insertiontorque
Norton,2011
Surgicalprocedure
Compressionnecrosis: Theorythatincreasedtorquecanimpedebloodcirculationandleadtobonenecrosis.Bothanimalandhumanstudieshavefailedtoconfirmthistheory.Itcouldonlybeconfirmedinosteotomesitepreparation.
Premolarimplantplacement• 1st premolaristhemostidealtoothinbotharches• Max1st premolarsoftenintheestheticzone• Implantshouldbeplacedunderthebuccalcusptoensureproperesthetics
• 4mmimplantdiameteristheclosesttotheaveragepremolarrootdiameter(4.2mm)
• Caninerootisoftenangleddistally (taperedimplantpreferred)
Molarimplantreplacement• Whenmorethan14mm
mesio-distaldistancetwosplintedimplantsinsteadofone
• Enameloplasty ,orimplantsmaybeoffsettoincreasespacebetweenthem
• Ideallocationtobeginwithimplantsurgeryposteriorsingletoothreplacement
Edentulousmandible
• Palpatelingualsideofmandibleforundercutsandcomparetodiagnosticimages
• Incision:>3mmofattachedKGcrestalincisionifnot1.5mmofKGshouldbepreservedonthefacial
Edentulousmandible
• Identifymentalforamen
Edetulous mandible• Flapsreflectedonthelingual
first• Retractionsutureswith2-0silk
areusedtokeepthelingualflapoutofthesurgicalsite
• Buccalflapisthenelevated• Positionofmentalforamina
determinesthenumberofimplantsintheanteriormandible
• Whenthenervesapproachesthecanalatthesameheightthereisnoanteriorloop
Suturing
• Twomechanismsofabsorption:digestionbyenzymesforsuturesofbiologicaloriginandbyhydrolysisforsyntheticpolymers(PGA-FA)
• 3-0tocloseflapsandthen4-0tocoapt thetensionfreeflapedges
• Significantincreaseinflapstrengthisobservedbetween1and2weeks
Suturing
Suturing
• Silk,e-PTFE,chromicgut,plaingutslipsurgicalknot
• SyntheticresorbableSurgeon’sknot
Suturing
• Usuallysingleinterruptedsuturesareindicated
• Flapsshouldbetensionfree• Needlepenetration2-3mmfromthewoundedges
• Horizontalmattresscanbeusedtoovercomemusclepull,andpreventflapopening
• Continuoussuturescanbeusedbutarenotrecommendedbecauseofthedisadvantages
Raghavendra etal.2005
ImplantStabilityAssessment
ØImpactbasedapproaches
PerioTest device(Schulteetal.1980)wasoriginallyusedforevaluationoftoothmobility.
ImplantStabilityAssessment
Ø Impactbasedapproaches
MeasurementleadstoPerioTestvalue(PTV),-8to50
PTVcorrelatestomobilityandlevelofmarginalbone
ImplantStabilityAssessmentØ Impactbasedapproaches
NocorrelationwasfoundbetweenPTVandBIC
Differentcriteriatoassessimplantandteethmobility
Limitedrangeofmeasurementsappliestoimplants(àlowsensitivity)
PTVstronglyinfluencedbythepositionofimpactlocationandbytheangleofthedevicerelativelytotheimplantaxis
à DifficulttousePerioTest formonitoringpurposesduetoreproducibilityandprecisionerrorrelatedissues.
ImplantStabilityAssessmentØ Resonancefrequencyanalysis
Measurementofthefirstresonancefrequencyofthebone– implantsystem.
UsesanL-shapedtransducerora“Smartpeg”,whichisapiecescrewedintheimplantabutment
MeasurementgivesanindexcalledImplantStabilityQuotient(ISQ0-100),systemiscommercializedunderthenameOsstell
ImplantStabilityAssessmentØ Resonancefrequencyanalysis
AcorrelationwasshownbetweeninitialISQvalueand1. cuttingtorque2. bonemeasurementsassessed
empiricallybythesurgeonduringimplantplacement
3. Corticalbonethickness4. Anatomicalregionofimplantation
ThereissignificantrelationshipbetweenLekholm&Zarbindexplacementtorque,ISQandPTVvalues
Quirynen etal,2006
OhandKim,2012
ImplantStabilityAssessmentØ Resonancefrequencyanalysis
Limitations:1. Onlycapturesthefirstresonancefrequency,whichisoflimited
valuefromastructuralmechanicspointofview(“oversimplification”)
2. SensitivityofISQvaluetotheimplantstabilitydependsontheimplanttype
3. RelationshipbetweenISQvaluesandBICremainsunclear4. Fixationandorientationofthetransducer(orsmartpeg)influence
significantlytheISQvalues5. ISQvaluesarerelatedtothebonepropertiesatthescaleofthe
organ,butpropertiesatthescaleof50-200μmarecriticalforosseointegration
6. Nocriteriaforimplantfailure
AntibioticsTanetal.2012
• 329healthypts• 4groups
– 2gramsofamoxicillin1hpre-op– 2gramsofamoxicillinimmediatelypost-op– 2gramsofamoxicillin1hpre-opand500mgq8hrsondays2and
3– Negativecontrol,2gramsofplacebopre-op
• Examinedcomplicationsupto8weeks,pt parametersandclinicaloutcome
• Results:Studyquestionsthenecessityofantibioticprophylaxis,whenimplantsareplacedinhealthypatientsandcasesare“straightforward”
Antibiotics
Ahmadetal.2012• Systematicreviewbetween1995and1/2009• Included6studies
Antibiotics
Ahmadetal.2012
Conclusion:Noclearevidenceontheliteraturepointingtotheneedforantibioticprophylaxisinconjunctionwithimplantplacement.
AntibioticsEspositoetal.2013
• 6Randomizedcontrolledclinicaltrials,1162participants• 4multicentertrialsand2single-centertrials
– 1gamoxicillin1hpre-opand500mgq6hrs for2daysvs noantibiotics
– 2gamoxicillin1hrpre-opvs placebo(3studies)– 2gamoxicillinvs noantibiotics;2gamoxicillin1hrpre-opand1gq
12hrsfor7days;1gamoxicillinpost-opq12hrsfor7days– 3gamoxicillinonehourpre-opvs placebo
Conclusion:Datato17June2013suggestthat2or3gamoxicillin1hrpre-oparebeneficialforreducingfailuresofdentalimplants (Givingantibioticsto25peoplewillavoid1failure).
References• Misch.DensityofBone:EffectonSurgicalApproachandHealing.pp 645-667.Contemporary
ImplantDentistry,Misch,C.E.,3rdEdition,2008,MosbyYearBook.• Misch.PosteriorSingleToothReplacement:SurgicalGuidelines (CH30).pp 668-683.Contemporary
ImplantDentistry,Misch,C.E.,3rdEdition,2008,MosbyYearBook.• Misch.RootformSurgeryintheEdentulousAnteriorandPosteriorMandible: ImplantInsertion(CH
31).pp 684-719.ContemporaryImplantDentistry,Misch,C.E.,3rdEdition,2008,MosbyYearBook.• Klokkevold,Han,Park.StandardImplantSurgicalProcedures.(CH71).pp 663- Carranza’sClinical
Periodontology;Newman,Takeietal.,2012,11thedition,Elsevier.• ErikssonRA,Albrektsson T.Theeffectofheatonboneregeneration:anexperimental studyinthe
rabbitusingthebonegrowthchamber. JOralMaxillofac Surg.1984Nov;42(11):705-11.• Sener BC,Dergin G,Gursoy B,Kelesoglu E,Slih I.Effectsofirrigationtemperatureonheatcontrolin
vitroatdifferentdrilling depths.Clin OralImplantsRes.2009Mar;20(3):294-8.• OhT,etal.Effectofflapless implantsurgeryonsofttissueprofile:Arandomizedcontrolledclinical
trial. JPeriodontol 2006;77:874-882• ParkJC,HwangJW,Lee JS,etal.Developmentoftheimplantsurgical techniqueandassessment
ratingsystem.JPeriodontalImplantSci.2012Feb;42(1):25-9.• Boioli Letal:Ameta-analytic,quatitative assessmentofosseointegrationestablishmentand
evolutio ofsubmergedandnon-submergedendosseoustitaniumoralimplants.Clin OralImplantsRes.12:579-88,2001
References• Valderrama P,etal.Evaluationoftwodifferentresonancefrequencydevices todetectimplant
stability:aclinical trial.JPeriodontol 200778:262-272.• BarewalRM,OatesTW,MeredithN,CochranDL.Resonance frequencymeasurementofimplant
stabilityinvivoonimplantswithasandblastedandacid-etchedsurface.Int JOralMaxillofacImplants.2003Sep-Oct;18(5):641-51.
• SilversteinLH.Essentialprinciples ofdentalsuturingfortheimplantsurgeon.DentImplantolUpdate.2005;16:1-7.
• SilversteinLH,KurtzmanGM,Shatz PC.SuturingforOptimalSoftTissueManagement.2009.JOralImplant35(2):82-90
• Khiste SV,Ranganath V,Nichani AS.Evaluationoftensile strengthofsurgicalsyntheticabsorbablesuturematerials:aninvitrostudy.JPeriodontalImplantSci.2013Jun;43(3):130-5.
• AhmadN,Saad N.Effectsofantibioticsondentalimplants:areview.JClin MedRes.2012Feb;4(1):1-6.
• EspositoM,Grusovin MG,WorthingtonHV.Interventionsforreplacingmissingteeth:antibioticsatdentalimplantplacement topreventcomplications.CochraneDatabaseSyst Rev.2013Jul31;7:CD004152.
• TanWC,etal.Effectofsystemicantibioticsonclinical andpatient-reportedoutcomesofimplanttherapy- amulticenter randomizedcontrolledclinical trial.Clin OralImplantsRes.2014
• Trisi,P.,Rebaudi A:Progressiveboneadaptationoftitaniumimplantsduringandafterorthodonticloadinhumans.Int JPeriodonticsRestorativeDent.2002Feb;22(1):31-43
References• Alsaadi,Getal:ABiomechanical assessmentoftherelationbetween theoralimplantstabilityat
insertionandsubjectivebonequalityassessment.JClin Carranza’sClinical Periodontology;Newman,Takeietal.,2012,11th edition,Elsevier
• OhJ,KimS,Clinical studyoftherelationshipbetweenimplantstabilitymeasurementsusingPeriotest andOsstell mentorandbonequalityassessment.OralSurg OralMedOralPathol OralRadiol.2012Mar;113(3):e35-40
• ImmediateLoading:ANewErainOralImplantology Testori,Tiziano;Galli, Fabio;DelFabbro.2010,QuintessencePublishing
• BarewalRetal:ResonanceFrequence Measurment onImplantStability inVivoonImplantswithaSandblastedandAcid– EtchedSurface.Int JOralMaxillofac Implants2003;18:641-651
• Jong-Chul Park,Jung-WooLee,Soung-MinKimandJong-HoLee (2011).ImplantStability-MeasuringDevicesandRandomizedClinical Trial forISQValueChangePatternMeasuredfromTwoDifferentDirectionsbyMagneticRFA,ImplantDentistry- ARapidlyEvolvingPractice,Prof.IlserTurkyilmaz (Ed.),ISBN:978-953- 307-658-4,InTech,Availablefrom:http://www.intechopen.com/books/implant-dentistry-a-rapidly-evolving- practice/implant-stability-measuring-devices-and-randomized-clinical-trial-for-isq-value-change-pattern-measu
Thankyou