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

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