basic and detail procedure

Surgical planning

Prior to commencement of surgery, careful and detailed planning is required to identify vital structures such as the inferior alveolar nerve or the sinus, as well as the shape and dimensions of the bone to properly orient the implants for the most predictable outcome. Two-dimensional radiographs, such as orthopantomographs or periapicals are often taken prior to the surgery. Sometimes, a CT scan will also be obtained. Specialized 3D CAD/CAM computer programs may be used to plan the case.

Whether CT-guided or manual, a 'stent' may sometimes be used to facilitate the placement of implants. A surgical stent is an acrylic wafer that fits over either the teeth, the bone surface or the mucosa (when all the teeth are missing) with pre-drilled holes to show the position and angle of the implants to be placed. The surgical stent may be produced using stereolithography following computerized planning of a case from the CT scan. CT guided surgery may double the cost compared to more commonly accepted approaches.

[edit]Basic procedure

In its most basic form the placement of an osseointegrated implant requires a preparation into the bone using either hand osteotomes or precision drills with highly regulated speed^[16] to prevent burning or pressure necrosis of the bone. After a variable amount of time to allow the bone to grow on to the surface of the implant (osseointegration), a crown or crowns can be placed on the implant. The amount of time required to place an implant will vary depending on the experience of the practitioner, the quality and quantity of the bone and the difficulty of the individual situation.

[edit]Detail procedure

At edentulous (without teeth) jaw sites, a pilot hole is bored into the recipient bone, taking care to avoid the vital structures (in particular theinferior alveolar nerve or IAN and the mental foramen within the mandible). Drilling into jawbone usually occurs in several separate steps. The pilot hole is expanded by using progressively wider drills (typically between three and seven successive drilling steps, depending on implant width and length). Care is taken not to damage the osteoblast or bone cells by overheating. A cooling saline or water spray keeps thetemperature of the bone to below 47 degrees Celsius (approximately 117 degrees Fahrenheit). The implant screw can be self-tapping, and is screwed into place at a precise torque so as not to overload the surrounding bone (overloaded bone can die, a condition called osteonecrosis, which may lead to failure of the implant to fully integrate or bond with the jawbone). Typically in most implant systems, the osteotomy or drilled hole is about 1mm deeper than the implant being placed, due to the shape of the drill tip. Surgeons must take the added length into consideration when drilling in the vicinity of vital structures.

contraindications

There are few absolute contraindications to implant dentistry. However, there are some systemic, behavioral and anatomic considerations that should be assessed.

Particularly for mandibular (lower jaw) implants, in the vicinity of the mental foramen (MF), there must be sufficient alveolar bone above themandibular canal also called the inferior alveolar canal or IAC (which acts as the conduit for the neurovascular bundle carrying the inferior alveolar nerve or IAN).

Failure to precisely locate the IAN and MF invites surgical insult by the drills and the implant itself. Such insult may cause irreparable damage to the nerve, often felt as a paresthesia (numbness) or dysesthesia (painful numbness) of the gum, lip and chin. This condition may persist for life and may be accompanied by unconscious drooling.

Uncontrolled type II diabetes is a significant relative contraindication as healing following any type of surgical procedure is delayed due to poor peripheral blood circulation. Anatomic considerations include the volume and height of bone available. Often an ancillary procedure known as a block graft or sinus augmentation are needed to provide enough bone for successful implant placement.

There is new information about intravenous and oral bisphosphonates (taken for certain forms of breast cancer and osteoporosis, respectively) which may put patients at a higher risk of developing a delayed healing syndrome called osteonecrosis. Implants are contraindicated for some patients who take intravenous bisphosphonates.

The many millions of patients who take an oral bisphosphonate (such as Actonel, Fosamax and Boniva) may sometimes be advised to stop the administration prior to implant surgery, then resume several months later. However, current evidence suggests that this protocol may not be necessary. As of January, 2008, an oral bisphosphonate study reported in the February 2008 Journal of Oral and Maxillofacial Surgery, reviewing 115 cases that included 468 implants, concluded "There is no evidence of bisphosphonate-associated osteonecrosis of the jaw in any of the patients evaluated in the clinic and those contacted by phone or e-mail reported no symptoms."^[31]

The American Dental Association had addressed bisphosphonates in an article entitled "Bisphosphonate medications and your oral health,"^[32] In an Overview, the ADA stated "The risk of developing BON [bisphosphonate-associated osteonecrosis of the jaw] in patients on oral bisphosphonate therapy appears to be very low...". The ADA Council on Scientific Affairs also employed a panel of experts who issued recommendations [for clinicians] for treatment of patients on oral bisphosphonates, published in June, 2006. The overview may be read online at ada.org but it has now been superseded by a huge study—encompassing over 700,000 cases—entitled "Bisphosphonate Use and the Risk of Adverse Jaw Outcomes." Like the 2008 JOMS study, the ADA study exonerates oral bisphosphonates as a contraindication to dental implants.^[33]

Bruxism (tooth clenching or grinding) is another consideration which may reduce the prognosis for treatment. The forces generated during bruxism are particularly detrimental to implants while bone is healing; micromovements in the implant positioning are associated with increased rates of implant failure. Bruxism continues to pose a threat to implants throughout the life of the recipient.^[34] Natural teeth contain a periodontal ligament allowing each tooth to move and absorb shock in response to vertical and horizontal forces. Once replaced by dental implants, this ligament is lost and teeth are immovably anchored directly into the jaw bone. This problem can be minimized by wearing a custom made mouthguard (such an NTI appliance) at night.

Postoperatively, after implants have been placed, there are physical contraindications that prompt rapid action by the implantology team. Excessive or severe pain lasting more than three days is a warning sign, as is excessive bleeding. Constant numbness of the gingiva (gum), lip and chin—usually noticed after surgical anesthesia wears off—is another warning sign. In the latter case, which may be accompanied by severe constant pain, the standard of care calls for diagnosis to determine if the surgical procedure insulted the IAN. A 3D cone beam X-ray provides the necessary data, but even before this step a prudent implantologist may back out or completely remove an implant in an effort to restore nerve function because delay is usually ineffective. Depending upon the evidence visible with a 3D X-ray, patients may be referred to a specialist in nerve repair. In all cases, speed in diagnosis and treatment are necessary.

Failure

Failure of a dental implant is often related to failure to osseointegrate correctly. A dental implant is considered to be a failure if it is lost, mobile or shows peri-implant (around the implant) bone loss of greater than 1.0 mm in the first year and greater than 0.2mm a year after.

Dental implants are not susceptible to dental caries but they can develop a condition called peri-implantitis. This is an inflammatory condition of the mucosa and/or bone around the implant which may result in bone loss and eventual loss of the implant. The condition is usually, but not always, associated with a chronic infection. Peri-implantitis is more likely to occur in heavy smokers, patients with diabetes, patients with poor oral hygiene and cases where the mucosa around the implant is thin.^[28]

Currently there is no universal agreement on the best treatment for peri-implantitis. The condition and its causes is still poorly understood.^[29]

Risk of failure is increased in smokers. For this reason implants are frequently placed only after a patient has stopped smoking as the treatment is very expensive. More rarely, an implant may fail because of poor positioning at the time of surgery, or may be overloaded initially causing failure to integrate. If smoking and positioning problems exist prior to implant surgery, clinicians often advise patients that a bridge or partial denture rather than an implant may be a better solution.

Failure may also occur independently of the causes outlined above. Implants like any other object suffers from wear and tear. If the implants in question are replacing commonly used teeth, then these may suffer from wear and tear and after years may crack and break up, although this is a very rare occurrence. The only way to minimize the risk of this happening is to visit your dentist for regular reviews.

In the majority of cases where an implant fails to integrate with the bone and is rejected by the body the cause is unknown. This may occur in around 5% of cases. To this day we still do not know why bone will integrate with titanium dental implants and why it does not reject the material as a 'foreign body'. Many theories have been postulated over the last five decades. A recent theory argues that rather than being an active biological tissue response, the integration of bone with an implant is the lack of a negative tissue response. In other word for unknown reasons the usual response of the body to reject foreign objects implanted into it does not function correctly with titanium implants. It has further been postulated that an implant rejection occurs in patients whose bone tissues actually react as they naturally should with the 'foreign body' and reject the implant in the same manner that would occur with most other implanted materials

source: wikipedia

Complementary procedures

Sinus lifting is a common surgical intervention. A dentist or specialist with proper training such as an oral surgeon, periodontist, general dentist, or prosthodontist, thickens the inadequate part of atrophic maxilla towards the sinus with the help of bone transplantation or bone expletive substance. This results in more volume for a better quality bone site for the implantation. Prudent clinicians who wish to avoid placement of implants into the sinus cavity pre-plan sinus lift surgery using the CBCT X-ray, as in the case of posterior mandibular implants discussed earlier.

Bone grafting will be necessary in cases where there is a lack of adequate maxillary or mandibular bone in terms of front to back (lip to tongue) depth or thickness; top to bottom height; and left to right width. Sufficient bone is needed in three dimensions to securely integrate with the root-like implant. Improved bone height—which is very difficult to achieve—is particularly important to assure ample anchorage of the implant's root-like shape because it has to support the mechanical stress of chewing, just like a natural tooth.

Typically, implantologists try to place implants at least as deeply into bone as the crown or tooth will be above the bone. This is called a 1:1 crown to root ratio. This ratio establishes the target for bone grafting in most cases. If 1:1 or more cannot be achieved, the patient is usually advised that only a short implant can be placed and to not expect a long period of usability.

A wide range of grafting materials and substances may be used during the process of bone grafting / bone replacement. They include the patient's own bone (autograft), which may be harvested from the hip (iliac crest) or from spare jawbone; processed bone from cadavers (allograft); bovine bone or coral (xenograft); or artificially produced bone-like substances (calcium sulfate with names like Regeneform; andhydroxyapatite or HA, which is the primary form of calcium found in bone). The HA is effective as a substrate for osteoblasts to grow on. Some implants are coated with HA for this reason, although the bone forming properties of many of these substances is a hotly debated topic in bone research groups. Alternatively the bone intended to support the implant can be split and widened with the implant placed between the two halves like a sandwich. This is referred to as a 'ridge split' procedure.

Bone graft surgery has its own standard of care. In a typical procedure, the clinician creates a large flap of the gingiva or gum to fully expose the jawbone at the graft site, performs one or several types of block and onlay grafts in and on existing bone, then installs a membrane designed to repel unwanted infection-causing microbiota found in the oral cavity. Then the mucosa is carefully sutured over the site. Together with a course of systemic antibiotics and topical antibacterial mouth rinses, the graft site is allowed to heal (several months).

The clinician typically takes a new radiograph to confirm graft success in width and height, and assumes that positive signs in these two dimensions safely predict success in the third dimension; depth. Where more precision is needed, usually when mandibular implants are being planned, a 3D or cone beam radiograph may be called for at this point to enable accurate measurement of bone and location of nerves and vital structures for proper treatment planning. The same radiographic data set can be employed for the preparation of computer-designed placement guides.

Correctly performed, a bone graft produces live vascular bone which is very much like natural jawbone and is therefore suitable as a foundation for implants.

source: wikipedia

Considerations

For dental implant procedure to work, there must be enough bone in the jaw, and the bone has to be strong enough to hold and support the implant. If there is not enough bone, more may need to be added with a bone graft procedure discussed earlier. Sometimes, this procedure is called bone augmentation. In addition, natural teeth and supporting tissues near where the implant will be placed must be in good health.

In all cases careful consideration must be given to the final functional aspects of the restoration, such as assessing the forces which will be placed on the implant. Implant loading from chewing and parafunction (abnormal grinding or clenching habits) can exceed the biomechanic tolerance of the implant bone interface and/or the titanium material itself, causing failure. This can be failure of the implant itself (fracture) or bone loss, a "melting" or resorption of the surrounding bone.

The dentist must first determine what type of prosthesis will be fabricated. Only then can the specific implant requirements including number, length, diameter, and thread pattern be determined. In other words, the case must be reverse engineered by the restoring dentist prior to the surgery. If bone volume or density is inadequate, a bone graft procedure must be considered first. The restoring dentist may consult with the oral surgeon, periodontist, endodontist, or another trained general dentist to co-treat the patient. Usually, physical models or impressions of the patient's jawbones and teeth are made by the restorative dentist at the implant surgeons request, and are used as physical aids to treatment planning. If not supplied, the implant surgeon makes his own or relies upon advanced computer-assisted tomography or a cone beam CT scan to achieve the proper treatment plan.

Computer simulation software based on CT scan data allows virtual implant surgical placement based on a barium impregnated prototype of the final prosthesis. This predicts vital anatomy, bone quality, implant characteristics, the need for bone grafting, and maximizing the implant bone surface area for the treatment case creating a high level of predictability. Computer CAD/CAM milled or stereolithography based drill guides can be developed for the implant surgeon to facilitate proper implant placement based on the final prosthesis' occlusion and aesthetics.

Treatment planning software can also be used to demonstrate "try-ins" to the patient on a computer screen. When options have been fully discussed between patient and surgeon, the same software can be used to produce precision drill guides. Specialized software applications such as 'SimPlant' (simulated implant) or 'NobelGuide' use the digital data from a patient's CBCT to build a treatment plan. A data set is then produced and sent to a lab for production of a precision in-mouth drilling guide.^[25]

^{source: wikipedia}

History

The Mayan civilization has been shown to have used the earliest known examples of endosseous implants (implants embedded into bone), dating back over 1,350 years before Per-Ingvar Brånemark started working with titanium. While excavating Mayan burial sites in Honduras in 1931, archaeologists found a fragment of mandible of Mayan origin, dating from about 600 AD. This mandible, which is considered to be that of a woman in her twenties, had three tooth-shaped pieces of shell placed into the sockets of three missing lower incisor teeth. For forty years the archaeological world considered that these shells were placed after death in a manner also observed in the ancient Egyptians. However, in 1970 a Brazilian dental academic, Professor Amadeo Bobbio studied the mandibular specimen and took a series of radiographs. He noted compact bone formation around two of the implants which led him to conclude that the implants were placed during life.

In the 1950s research was being conducted at Cambridge University in England to study blood flow in vivo. These workers devised a method of constructing a chamber of titanium which was then embedded into the soft tissue of the ears of rabbits. In 1952 the Swedish orthopaedic surgeon, P I Brånemark, was interested in studying bone healing and regeneration, and adopted the Cambridge designed ‘rabbit ear chamber’ for use in the rabbit femur. Following several months of study he attempted to retrieve these expensive chambers from the rabbits and found that he was unable to remove them. Per Brånemark observed that bone had grown into such close proximity with the titanium that it effectively adhered to the metal. Brånemark carried out many further studies into this phenomenon, using both animal and human subjects, which all confirmed this unique property of titanium.

Meanwhile an Italian medical doctor called Stefano Melchiade Tramonte, understood that titanium could be used for dental restorations and after designing a titanium screw to support his own dental prosthesis, started to use it on many patients in his clinic in 1959. The good results of his clinical studies on humans were published in 1966.^[1]

Although Brånemark had originally considered that the first work should centre on knee and hip surgery, he finally decided that the mouth was more accessible for continued clinical observations and the high rate of edentulism in the general population offered more subjects for widespread study. He termed the clinically observed adherence of bone with titanium as ‘osseointegration’. In 1965 Brånemark, who was by then the Professor of Anatomy at Gothenburg University in Sweden, placed his first titanium dental implant into a human volunteer, a Swede named Gösta Larsson.

Contemporaneous independent research in the United States by Stevens and Alexander led to a 1969 US patent filing for titanium dental implants.^[2]

Over the next fourteen years Brånemark published many studies on the use of titanium in dental implantology until in 1978 he entered into a commercial partnership with the Swedish defense company, Bofors AB for the development and marketing of his dental implants. With Bofors (later to become Nobel Industries) as the parent company, Nobelpharma AB (later to be renamed Nobel Biocare) was founded in 1981 to focus on dental implantology. To the present day over 7 million Brånemark System implants have now been placed and hundreds of other companies produce dental implants. The majority of dental implants currently available are shaped like small screws, with either tapered or parallel sides. They can be placed at the same time as a tooth is removed by engaging with the bone of the socket wall and sometimes also with the bone beyond the tip of the socket. Current evidence suggests that implants placed straight into an extraction socket have comparable success rates to those placed into healed bone.^[3] The success rate and radiographic results of immediate restorations of dental implants placed in fresh extraction sockets (the temporary crowns placed at the same time) have been shown to be comparable to those obtained with delayed loading (the crowns placed weeks or months later) in carefully selected cases^[4]

Some current research in dental implantology is focusing on the use of ceramic materials such as zirconia (ZrO₂) in the manufacture of dental implants. Zirconia is the dioxide of zirconium, a metal close to titanium in the periodic table and with similar biocompatibility properties.^[5] Although generally the same shape as titanium implants, zirconia, which has been used successfully for orthopaedic surgery for a number of years, has the advantage of being more cosmetically aesthetic owing to its bright tooth-like colour.^[6] However, long-term clinical data is necessary before one-piece ZrO₂ implants can be recommended for daily practice.^[7]

 ^{source:wikipedia}

formation

Training

While there is no specialty recognized by the ADA for dental implants, there are two surgical specialties in dentistry, Oral Surgery and Periodontics, and the Standard of Care for surgical procedures are set by those two specialties. Implant surgery may be performed as an outpatient under general anesthesia, oral conscious sedation, nitrous oxide sedation, intravenous sedation or under local anesthesia by trained and certified clinicians including periodontists, oral surgeons, general dentists, and prosthodontists.

The legal training requirements for dentists who carry out implant treatment differ from country to country. In the UK implant dentistry is considered by the General Dental Council to be a postgraduate sphere of dentistry. In other words it is not sufficiently covered during the teaching of the university dental degree course and dentists wishing to practice in dental implantology legally need to undergo additional formal postgraduate training. The General Dental Council has published strict guidelines on the training required for a dentist to be able to place dental implants in general dental practice.^[11] UK dentists need to complete a competency assessed postgraduate extended learning program before providing implant dentistry to patients.

The degree to which both graduate and post-graduate dentists receive training in the surgical placement of implants varies from country to country,^[12][13][14] but it seems likely that lack of formal training will lead to higher complication rates.^[15]

who is a implant?

          implant

• fix or set securely or deeply; "He planted a knee in the back of his opponent"; "The dentist implanted a tooth in the gum"
• become attached to and embedded in the uterus; "The egg fertilized in vitro implanted in the uterus of the birth mother with no further complications"
• plant: put firmly in the mind; "Plant a thought in the students' minds"
• a prosthesis placed permanently in tissue
  wordnetweb.princeton.edu/perl/webwn
• "The Implant" is the 59th episode of the sitcom Seinfeld. It is the 19th episode of the fourth season, and first aired on February 25, 1993.
  en.wikipedia.org/wiki/The_Implant
• An implant is a medical device manufactured to replace a missing biological structure, support a damaged biological structure, or enhance an existing biological structure. Medical implants are man-made devices, in contrast to a transplant, which is a transplanted biomedical tissue. ...
  en.wikipedia.org/wiki/Implant_(medicine)

Dental

A dental implant is an artificial tooth root used in dentistry to support restorations that resemble a tooth or group of teeth.

Virtually all dental implants placed today are root-form endosseous implants. In other words, virtually all dental implants placed in the 21st century appear similar to an actual tooth root (and thus possess a "root-form") and are placed within the bone (end- being the Greek prefix for "in" and osseous referring to "bone").

Prior to the advent of root-form endosseous implants, most implants were either blade endosseous implants, in that the shape of the metal piece placed within the bone resembled a flat blade, or subperiosteal implants, in which a framework was constructed to lie upon and was attached with screws to the exposed bone of the jaws.

Dental implants can be used to support a number of dental prostheses, including crowns,implant-supported bridges or dentures.

source: wikipedia