bone grafting for implants.ppt
TRANSCRIPT
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Bone Grafting for implants
Dept. of Oral and Maxil lofacial Surgery, School of Dentistry,
Wonkwang Univ.
Kwon, Kyung-Hwan
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Diagnosis and Treatment Planning For Bone Augmentation
A complete intraoral examination Radiographs and in select cases a
CT scan Neurovascular bundles must be avoided. Paranasal sinus must be identified.
Study models
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Clinical Examination
Minimal obtain 1 to 2mm of attached gingiva
Cross section of the alveolar depicting periodontal probe placement for “sounding the bone”.
To determine bone width Cutting the study model in the exact
vertical location
Diagnosis and Treatment Planning For Bone Augmentation
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To Determine Bone Width
Harry Dym, Orrett E. Ogle: Atlas of Minor Oral Surgery. W.B. Saunders company. 2001
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Radiographic Examination
Panoramic radiograph 20 to 30% distortion/magnification of
the anatomic structures Buccal to lingual width will not be
appreciated Alveolar bone height, adjacent teeth
and anatomic structure
Diagnosis and Treatment Planning For Bone Augmentation
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Fabricate a surgical stent Guiding to the exact site of implant
placement Diagnostic wax-ups
Arch form, tooth spacing, and bony contour
Study Models
Diagnosis and Treatment Planning For Bone Augmentation
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Types of Bone Grafts
Autograft A graft taken from on anatomic location and placed in
another location in the same individual(e.g., iliac crest)
Allograft A graft taken from a cadever treated wit certain
sterilization and antiantigenic procedures and placed into a living host
Alloplast A chemically derived nonanimal material
Xenograft A graft taken from a nonhuman host for implantation into
a human host
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Biology of Bone Grafts
Phase I Osteogenesis: Immediate proliferation of
transplanted osteocytes and subsequent formation of osteoid(immature bone)
Phase II Osteoinduction: inducement of mesenchymal
cells to produce bone(BMP) Osteoconduction: framework or scaffold for the
formation of new bone tissue
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Mandibular Ramus
To create an incision starting on the lateral border of the ramus approximately 1.5cm above the mandiblular occlusal plane and ending at the mandibular second molar region
#9 Molt periosteal elevator: full thickness mucoperiosteal flap
Harvesting Techniques I
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0.9% Sodium chloride solution/ Crushed into small particles or used as block
Mandibular Ramus
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Mandibular Tori as a Donor site
Harvesting Techniques II
Monobevel Chisel is used, With the bevel positioned facing the l ingual cortex
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Grafting of the Extraction Socket
The teeth are extracted atraumatically preserving the buccal bone.
All granulation tissue is excised with the use of a surgical curette or a Rongeur.
DFDBA(deminerized freeze-dried bone allograft) + Gore Tex Mem.
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Extraction Socket Grafting
A. Extraction socket with particulate graft in placeB. Closure of extraction site with interdigitating
papil lae
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Cortical Onlay Bone Graft
Inadequate buccal to lingual/palatal width
Autogenous bone: donor sites-mandibular symphysis, mandibular ramus, calvarium or iliac crest
Allografts: demineralized freeze dried bone allograft blocks, freeze-dried blocks, and/or particles
Harvesting Techniques II I
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Bone Harvasting from the Chin
Buccal sulcus incision: canine to caine
Full-thickness mucoperiosteal flap Avoid the mental nerve
Level approximately 5mm below the apices of the mandibular anterior teeth
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Small curve monoplane osteotome
Hemostasis: Avitene(MedChem Products Inc., Woburn, MA)
3-0 Vicryle suture on a tapered needle
First approximate periosteum with multiple intterupted sutures being careful to maintain the mentalis muscle
Bone Harvasting from the Chin
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그림
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Interpositional Ridge Graft
The approximate depth of the osteotomy should be 1cm.
A bibevel chisel is used to gently outfracture the buccal plate and allow enough width for the proposed implant
Split ridge technique
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Rigde split technique 에 대한 그림
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Sinus-Lift Procedure
Dept. of Oral and Maxil lofacial Surgery, School of Dentistry,
Wonkwang Univ.
Kwon, Kyung-Hwan
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Sinus-Lift Procedure definition
Taum OH(1977) Introduced crestal approach to the sinus
membrane In 1986, modified Caldwell-Luc lateral
window
The grafte material is inserted between the antral floor and the Schneiderian membrane(lining of the maxillary sinus floor)
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Evaluation of Sinus
Fixture failure will result because of the downgrowth of antral epithelium aroud the fixture rather than by the superior growth of oral epithelium
Protocol of Sinus Lifting Indication 4 mm below: Lateral window technique 4-6mm :Summer’s Osteotome technique 6mm above: Simultaneous implant with bone
grafting
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Graft Material for Sinus Lift
Autogeous Bone Hip/ Tibia/ Symphysis/ Ramus/ Maxillary
tuberosity Allograft(obtained from human cadavers)
Freeze-dried bone/DFDB Xenografts(Bone from nonhuman species)
Bovine bone(Bio-Oss) Alloplastic(Natural and synthetic bone
substitute) Hydrozyapatite/ Tricalcium phosphate(TCP)/
Bioactive glass ceramics
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Time Tables
Waiting between 4 and 9 after grafting for implant placement and an additional 4 to 6 months before placing final restoration
In my clinics, Simultaneous implantation study show result of 95% success rate. but, case by case
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Surgical Protocol
Maxil lary Sinus Lift ing Technique
A B C D
A: Sagittal view of maxil lary sinus showing relationship of sinus membraneB: Showing outl ine of bony cuts for creation of lateral windowC: Mucosal flap elevated and slow round bur being used to create bony windowD: Antral membrane shown tented upwards with implant place and bone fil l ing
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Surgical Protocol
Round diamond #6 burr Surgical curette is place in the edges of
the inferior osteotomy between the bone and the antrum and gently used to peel away the membrane from the inside wall of the sinus
Perforation of membrane: CollaTape used Leave sutures in place fo 7 to 10 days Antibiotics, analgesics and decongestant
coverage
Maxil lary Sinus Lift ing Technique
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Not wear a removable appliance for the first 2 postoperative weeks
The most common postoperative complication: Infection- irrigated daily until resolution
Maxil lary Sinus Lift ing Technique
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Sinus lifting 그림
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Principles of Implant Surgery
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Essential Critical Factors-Implant placement success-
Minimal trauma Biocompatible material Buried and untouched for 3 to 4
months before prosthetic loading Copious internal or external irrigation
to minimize thermal bone demage Precious attachment of implant and
prosthesis
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Relative Contraindications
Uncontrolled diabetic patient Significant smocking history
Jawbone irradiation less than 1 year before implant placement
Acute psychotic disorders Severe bone resorption in patient
who refuses bone grafting
Implant Placement
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Minimal Dimensional Parameters
At least 1mm of excess bone: both the lingual and buccal or labial side
At least 2 mm of bone: implant and any adjacent tooth or implant
Vertical ridge height must ideally provide a 1- or 2 mm margin of safety from the inferior alveolar mandibular canal, maxillary sinus, and other adjacent vital structures
Adequate vertical space: minimum of 8mm
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Implant Work-Up ProtocoI(1)
Appropriate X-rays Panoramic film Periapical X-rays CAT scan(if deemed necessary) Lateral cephalogram(when indicated in
edentulous lower arch)
Models of upper/lower arches
Mock wax-up of missing teeth on mounted upper/lower casts
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Fabrication of plastic stent Peper tacing: sinus and inferior
alveolar nerve Detect thickness and concavities Evaluation of existing periodontal
condition Patient education: Risks and
complication
Implant Work-Up Protocol(2)
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Diagnostic and Surgical Implant Placement Protocol
Initial Dental Consultation Clinical Evaluation and Diagnosis
Therapeutic Plan Presurgical Mouth Preparation
Surgical Implantation
Prosthetic Management Follow-Up Care and Maintenance
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Initial Dental Consultation
Patient’s reason an motivation for dental consulatation
Etiology of edentulous or patially edentulous state
General medical history Indications and contraindications Specific dental/oral complaints Oral Examination Psychosocial evaluation Preliminary diagnosis
Diagnostic and Surgical Implant Placement Protocol (1)
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Clinical Evaluation and Dx.
Review of indications and contraindications Oral examination Evaluation of existing dentition Periodontal evaluation: prophyaxis Occlusal analysis Analysis of models in a semiadjastabl articulator Radiographic findings Full mount Panorex radiogaph Specific periapical and/or lateral jaw radiographs Photographic documentation
Diagnostic and Surgical Implant Placement Protocol(2)
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Therapeutic Plan
Implant position and sizes Prosthetic restoration
Explanation of treatment plan Establishment of treatment sequence
and schedule Establishment of financial
arrangements
Diagnostic and Surgical Implant Placement Protocol(3)
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Presurgical Mouth Preparation
Extractions
Necessary restorative dental procedures
Periodontal therapy
Endodontal therapy
Orthodontal therapy
Prophylatic splinting
Presurgical measurement radiograph with surgical template in place
Diagnostic and Surgical Implant Placement Protocol(4)
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Surgical Implantation
Confirm measurement of potential implant sites on radiograph
Positioning of the surgical template Surgical insertion of implant(Stage 1)
Reopening of the implant sites(Stage 2) Removal of first phase healing screw
Diagnostic and Surgical Implant Placement Protocol(5)
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Prosthetic Management
Preparation of adjacent natural teeth Removal of second phase healing
screw Making impression
Fabrication of master model Try-un and adjustment of prosthesis Delivery of prosthesis
Diagnostic and Surgical Implant Placement Protocol(6)
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Follow-Up Care and Maintenance
Oral prophylaxis
Periodotnal evaluation
Oral hygiene reeducation and remotivation
Implant recommandation
Diagnostic and Surgical Implant Placement Protocol(7)
Partial Denture ? Or Implant?