HandOutforVDDS

Transcript HandOutforVDDS

Prevention and Management Of Complications In Implant Dentistry

Evidence Based Medicine / Dentistry

EBM is the conscientious, explicit and judicious use of best evidence in making decisions about care of individual patients.

Cochrane Center Oxford, England

3 Components of Evidence Based Dentistry

1) Scientific Literature 2) Professional Experience and advise 3) Patient’s treatment desire and goal

“Train The Brain”

Dr. Mark H.E. Lin

Complications In Implant Dentistry Systemic Conditions Host / Patient Related Dentist / Surgeon Related Clinical Protocol Related Treatment Planning Local Factors Psychological Status Smoking Periodontitis Surgical Prosthetic Restorative Grafting Maintenance

Host / Patient Related: Medical Status

Absolute

Contraindications to Surgery

Relative

Contraindications / Risk Factors to Surgery

Susceptibility to Infections and healing response in question

Host / Patient Related: Medical Status:

Absolute

Contraindications

For Surgery (Dental alveolar, implant, hard or soft tissue grafting) –

Debilitating diseases:

•

Active cancer

• • •

chemotherapy radiation therapy transmittable infections- hepatitis, HIV

–

Impaired healing capacity diseases:

•

Uncontrolled diabetes

• • •

Uncontrolled hypertension immune compromised disease history of osteomylitis in operative site

Host / Patient Related: Medical Status:

Absolute

Contraindications

– Recent myocardial infarction (M.I.), cerebrovascular accident, uncontrolled clotting / bleeding disorders – Pregnancy – Chronic or severe alcoholism – Drug abuse – Psychiatric disorders –

I.V. bisphosphonate use or long term oral bisphosphonate

– Uncontrolled periodontal disease – ASA IV or V patients

Host / Patient Related: Medical Status:

Relative Contraindications / Risk Factors

For Surgery (Dental alveolar, implant, grafting) – Debilitating diseases: Inactive cancer – Impaired diseases: Controlled diabetes, controlled hypertension – Myocardial infarction (M.I.) history of >1 year – Oral bisphosphonate – Smoking habits – Periodontal disease

American Society of Anesthesiologists (ASA) Classifications ASA I: a normal, healthy patient, without systemic disease.

ASA II: a patient with mild to moderate systemic disease.

ASA III: a patient with severe systemic disease, which limits or alters activity but is not incapacitating.

ASA IV: a patient with severe systemic disease, which is incapacitating and is a constant threat to life.

ASA V: a moribund patient not expected to live more than 24 hours without an operation.

Elective Implant surgeries are NOT indicated for ASA IV or V patients

For a patient at risk, strict adherence to the standard protocol does

not always

the expected results.

yield

Infection

Invasion and multiplication of microorganisms in body tissues, which may be clinically inapparent or result in local cellular injury due to competitive metabolism, toxins, intracellular replication, or antigen-antibody response.

Dorland’s Illustrated Medical Dictionary 27 th , Edition

Factors Associated with Increased risk of infection for dental implant procedures

Systemic Factors

1. Diabetes 2. Long term corticosteroid use 3. Immunocompromised systemic disorders 4. Smoking 5. Malnutrition, obesity 6. Elderly population 7. ASA III or IV classifications

Factors Associated with Increased risk of infection for dental implant procedures

Local Factors

1. Use of type or procedures of graft material 2. Generalized periodontal disease 3. Tissue inflammation 4. Odontogenic infections 5. ill-fitting provisional prosthesis 6. Incision line opening 7. Inadequate oral hygiene

Factors Associated with Increased risk of infection for dental implant procedures

Surgical Factors

1. Poor aseptic technique 2. Compromised skill and experience of the surgeon 3. Increased duration of surgical time 4. Wound contamination during surgery 5. Foreign body introduction (graft material, implants, debris, etc….)

Infection Prophylaxis

1) Aseptic Surgical techniques applied during all clinical grafting procedures.

2) Pre-operative Rx: Amoxicillin 500mg x 4 tablets (2 g), 1 hour prior to surgery (Scientific Evidence) Post-operative 1 tablet t.i.d. for 1 week following surgery (Optional)

Infection Prophylaxis

3) Chemical Plaque control: Preoperative rinsing with .12% Chlorhexidine digluconate for 1 minute.

Postoperative rinsing for 2-3 weeks with good oral hygiene.

4) Monitor and close follow up: Patient to return to clinic at 1-2 weeks to evaluate healing status.

Infection Prophylaxis

5) Confirm lack of localized infection from adjacent tooth (endodontic origin) or soft tissues (periodontitis) spreading into grafting site.

Diabetes

1. Higher prevalence in Adult African Americans, native and Hispanic Americans 2. Risk factors: Genetics, obesity, advancing age and inactive lifestyles.

3. Characterized by: 1. Peripheral resistance to insulin 2. Increased production of glucose by the liver 3. Altered pancreatic insulin secretion.

Oral Manifestations for a Diabetic Patient 1.

Poor wound healing (soft tissues, osseointegration) Higher susceptibility to oral infections Xerostomia Higher incidence of dental caries Pronounced hyperplasia of attached gingival Increased accumulation of plaque and food debris Neuropathy (burning mouth, tingling, numbness) Greater incidence and severity of periodontal disease Candidiasis and lichenoid reactions

Signs of

Hypoglycemia:

1. Sweating 2. Palpitations 3. Tachycardia 4. Nausea 5. Hunger 6. Tremulousness 7. The symptoms may progress to coma and convulsions without intervention.

Management of type I diabetic patients: (To prevent Insulin shock) 1. Patient instructed to take their usual dosage of insulin medications 2. To eat a normal meal prior to appointment 3. Schedule the appointment early in the morning 4. Patient to communicate with dentist if they feel symptoms of an insulin reaction 5. A source of sugar available in office (orange juice, candy, sugar packs) 6. May consider Antibiotic prophylaxis coverage to prevent infections which is related to the fasting blood glucose levels.

Dental Managements

1. Minimize stress 2. Decrease risks of infection (Post operative antibiotics: Amoxicillin 500 mg, t.i.d. or Clindamycin 300 mg, t.i.d. for 7-10 days) 3. Avoid untoward metabolic imbalances during dental therapy 4. Instructions for diet and medications to avoid hypoglycemia.

Management of Hypoglycemia

1. Sugar source readily available (sugar packets, candy, orange juice) 2. Dextrosol 3mg tablets of glucose 3. Glucagon 1 mg IM 4. 50% Glucose solution 50 ml IV

Bisphosphonates Induced Osteonecrosis of the Jaws (ONJ)

Defined as a non healing bone in the mandible or maxilla present for 8 weeks in a person that is on Bisphosphonates and hasn’t received radiation to the jaws.

Risk of osteonecrosis of the jaws • Exposed bone is dead with usually no pain.

• Pain may occur due to secondary infection • The jaw bones are susceptible because the jaw bone remodels 10 times that of long bones in the body.

Bisphosphonates

• Used for treatment of osteoporosis, metastatic bone cancer and Paget’s disease.

• Oral form: Fosamax, Boniva, Actinol • IV form: Aredia, Zonita

Mechanism of Bisphosphonates

• Mechanism of action by suppressing and reducing bone resorption by osteoclasts.

• Bisphosphonates inhibit osteoclasts by killing them when they take up the drug during resorption.

• Bisphosphonates binds to the hydoxyapatite in the bone

Bisphosphonates

• IV medications are worse then oral types.

• Risk increase after being on oral medications for > 3 years.

• IV takes 6 months to build to toxic level • Oral takes 3 years to build to toxic level • 140 IV reported cases versus 40 Oral cases • Incidence: IV: • Incidence: Oral: .8%-12% .01%-1%

Signs of ONJ

• Sclerosis and thickening of the lamina dura • Widening of the periodontal ligament (PDL) • Mobile teeth with pain • Exposed bone with necrosis of bone and soft tissues • Non healing bone post surgical wound

Treatment of ONJ

• We don’t know what is the best treatment protocol.

Dr. Robert Marx

seems to be the expert on this topic.

• Peridex rinse over surgical wound • Antibiotics: a) Pen VK b) Levoquin (limit to 21 days due to liver toxicity) • Reduce risk of secondary infections and osteomylitis of the jaws.

• 50 % of cases will spontaneously heal.

• 50 % of cases will require additional surgeries.

Prevention of ONJ

• Non invasive dental procedures are safe.

• Invasive dental procedures safe before 3 years.

• After 3 years- a drug holiday with consent of prescribing physician to a CTX of >= 150 pg/ml.

Serum C terminal telopeptide test (CTX)

• After 3 years of Bisphosphonate use, need a CTX to determine safety level.

• CTX <= 100 pg/ml: • CTX = 101-150 pg/ml: Moderate risk • CTX >= 150 pg/ml: HIGH risk Low risk • CTX improves significantly with discontinued oral Bisphosphonates use.

• CTX is a marker for bone turnover and healing.

• Measures osteoclast function as a C terminal fragment is cleaved during bone resorption.

Suggested

Treatment Regimen

• 1) Obtain references for CTX level • 2) Drug holiday of 4-6 months with approval from prescribing physician.

• 3) Treat with Peridex (.12%) and antibiotics.

• 4) Monitor CTX until value is >150 pg/ml • 5) Decide to refer or monitor for treatment options: A) Spontaneous resolution B) Treat surgically

Host / Patient Related: Psychological Status

1. Psychological and mental stability for patient to accept and tolerate required procedures 2. Normal healing response and sequelae of bone and soft tissue grafting procedures 3.

The 3 “C’s” prior to treatment: a) Communication b) Compliance c) Consent

Host / Patient Related:

Normal healing response and sequelae of bone and soft tissue grafting procedures are: •

Hemorrhage / bleeding

•

Ecchymosis / bruising

•

Pain / discomfort

•

Swelling

Hemorrhage / bleeding Management

1) Management of intra operative bleeding source (soft tissue / bone) prior to suturing.

2) Proper soft tissue suturing techniques to ensure primary closure without tension of soft tissues.

3) Proper use of sterile gauze pads with moistened sterile saline solution with FIRM pressure over wound for 20 minutes.

4) Oral and written instructions for care to prevent vasoactive substance (caffeine or alcohol), minimize exercise, post operative care to minimize disturbance to wound clotting, oral hygiene instruction care.

Ecchymosis (Bruising)

• Due to extravasation and subsequent breakdown of blood in the subcutaneous tissues.

• Deposition of blood from the surgery in the interstitial tissues spaces and will be resorbed over a time period of 1-3 weeks.

• Occurs more in fair skinned patients and elderly patients with fragile capillaries.

Ecchymosis Management

1) Inform patient that it will be a normal sequelae of any surgical procedure. 2) Inform patient that degree of bruising is NOT an indicator of success / failure, traumatic / atraumatic nature of procedure or operator.

3) Application of ice bag or cold packs immediately after surgery for 2 days.

Pain / discomfort Management

1) Long term Local anesthetics: a) Bupivacaine (Marcaine / Vivacaine): 0.5% w 1:200,000 epinephrine used for block anesthesia. Duration time of 6-8 hours.

b) Articaine (Ultracaine Forte / Astracaine): 4% w 1: 200,000 epinephrine. Duration time of 4 hours.

2) Analgesics: a) NSAIDS: Ibuprofen 400mg (600-800mg if anticipate swelling), 1 hour prior to surgery, then 1 tablet every 6-8 hours continuous for 2-3 days.

b) Narcotics: Tylenol #3, 1-2 tablets every 4-6 hours as required for pain relief.

Swelling Management

1) Application of ice bag or cold packs immediately after surgery for 2 days.

2) I.V. administration of glucocorticoid steroids (prednisolone 250mg or dexamethasone 8 mg) prior to start of surgery.

3) I.M. administration of Dexamethasone / Decadron (Celestone Soluspan Injectable)6mg/per site adjacent to surgical wound.

4) P.O. prescription of Dexamethasone (Decadron) 4 mg with regimen as follows: – Preoperative 4mg x 2 tablets = 8 mg, 1hour prior to surgery – Postoperative 4mg x 1 tablet = 4 mg, 1 st day after surgery – Postoperative 4mg x .5 tablet = 2 mg, 2 nd day after surgery – Postoperative 4mg x .5 tablet = 2 mg, 3 rd day after surgery

Complication

A secondary disease or condition aggravating an already existing one.

Dorland’s Illustrated Medical Dictionary 27th, Edition

Complication

Defined as a secondary condition that developed during or after implant surgery or prosthesis placement. The occurrence of a complication does not necessarily indicate that substandard dental care was provided and also does not necessarily mean that clinical failure has occurred.

Sequelae

Any lesion, condition, consequence or affection following a clinical procedure injury or caused by an attack of previous disease.

Dorland’s Illustrated Medical Dictionary 27th, Edition

a) Communication

Share or exchange information, news, or ideas

Oxford Dictionary 10th Edition

Allocate appropriate amount of TIME to educate and communicate prior to consent to treatment. Utilize patient education video, documents and software to aid in communication process.

b) Compliance

Disposed to agree with others or obey rules, especially to an excessive degree. Meeting or in accordance with rules or standards.

Oxford Dictionary 10th Edition

A quality of yielding to pressure or force without disruption, or an expression of the measure of the ability to do so.

Dorland’s Illustrated Medical Dictionary 27th, Edition

COMPONENTS OF CASE MANAGEMENT FOR IMPROVED CASE ACCEPTANCE RATE

New Patient Telephone Interview New Patient First Appointment Interview/ Consultation Interview Diagnostic Records Appointment - Consult with Specialists and Labs Case Presentation(Within 1 Week), (Bring Spouse) Acceptance Pre-Appointment Work Up -Pre Medications -Inform Consents -Financial Arrangements Confirmed -Diagnostic Work Up -Q/A Period Treatment Pending Case Discussion Letter Follow Up Report(1wk, 2 wks, 1 months) Post Treatment Interview -Follow Up photos for Patients B/A -Request for Testimonial Letter -Referral Request

c) Consent Process

1. Communication and patient education 2. Process of informed consents and financial arrangements confirmed 3. Relationship and rapport development with patients 4. Continuous monitoring support, empathy and sincere compassionate care

Consequences of Smoking on wound healing 1. Arteriolar vasoconstriction reduces vascularization and microcirculations of tissues.

2. May lead to increase incidence of flap necrosis and dehiscence to early graft exposures.

3. Tobacco's toxic byproducts have been implicated as risk factors for impaired healing.

Studies on Smoking and Implants

Study # 1:

5% lost on non-smokers versus 11% on smokers. Smokers with higher implant failure rates in all regions except for the posterior mandible.

Study # 2:

3% lost on non-smokers versus 7% on smokers by number of implants. 9% lost on non-smokers versus 22% on smokers by number of patients. Regardless of method of analysis, a

SIGNIGICANT

difference was noted between smokers and non-smokers.

Studies on Smoking and Implants

Study # 3:

Smoking cessation protocol of 1 week before surgery and 8 weeks after surgery.

-6% implant lost on non-smokers.

-38% implant lost on smokers WITHOUT smoking cessation program.

-12% implant lost on smokers WITH smoking cessation program.

Cessation protocol demonstrated improving implant success on treatment of smokers.

Effect of smoking (evaluated in 9 studies) -Significantly increases implant loss -Consumption increases failures (2 studies) -Consumption does note increase failure (1 study) -Comparison (smokers/nonsmokers) 178 / 1668 implants lost in smokers (11%) 239 / 4862 implants lost in non-smokers ( 5%)

Management protocol for smokers 1) Don’t treat!

2) Smoking cessation programs 3) Treat with consent form

Tobacco and Nicotine Warning Consent forms

Nicotine and Tobacco Warning

The nicotine in tobacco constricts the blood vessels of your body. This effect is immediate and lasts up to one month. Furthermore, nicotine will reduce the amount of oxygen delivered to the body. This constriction of blood vessels and reduced oxygen delivered will affect the circulation of the tissues handled. Implant surgery and bone grafting may require extensive manipulation of soft tissues. The use of nicotine can compromise the healing and cosmetic outcome of these surgeries. YOU MUST STOP SMOKING one month prior to surgery. You must not smoke for at least three weeks following surgery. A nicotine patch may be used to help stop smoking. However, no nicotine patch or nicotine gum may be used one month prior to surgery and for three weeks after surgery. ________________________ Parent Signature ________________________ Witness Signature _______________________ Date _______________________ Date

Periodontal disease and Dental Implants 1. Implant survival in patients with a history of treated Periodontitis ranged from 59-100% 2. 17/18 studies reported high implant survival rates of >= 90% with turned or moderately rough implant surfaces 3. Need for continue regular supportive periodontal therapy 4. Statistically significantly greater risk of peri implantitis, odds ratio of 3.1 to 4.7

Iatrogenic

Any adverse condition in a patient occurring as the result of treatment by a physician / dentist or surgeon, especially to infections acquired by the patient during the course of treatment.

Dorland’s Illustrated Medical Dictionary 27 th , Edition

Implant Treatment Planning Implantology is a “Prosthetically / Restorative” driven discipline with a “Surgical” component.

Treatment Sequence

Esthetic Implant Dentistry, Patrick Palacci, DDS

Improper Implant Treatment Planning 1) Improper surgical implant placements without desired prosthetic goals treatment planned 2) Improper use of number and location of dental implants for final prosthesis 3) Lack of understanding of Biomechanical rationale requirements for functional loads

Pretend the following: -you had all the time -you had all the money -you had all the bone -you had all the compliance What is the most ideal treatment plan desired for your patient?

Treatment planning philosophy- one of the most important factor to success

• • •

Don’t compromise your ideal treatment plan with the following: patient’s financial constraints.

-unreasonable time demands for completion.

• •

-insurance limitations or moral compromises.

patient’s guidance on treatment decisions.

•

(i.e. less implants, omit required

“The Lost Syndrome”

1) Lost trust from the patient!

2) Lost patience from the patient who will require more surgeries and procedures!

3) Lost time and require to start again from a clinical condition in a MORE compromised state!

4) Lost clinical chair time to redo the case!

5) Lost lots of money to redo the case!

6) Lost of peace of mind! (Lawsuit or Regulatory College Complaint?)

Treatment planning philosophy- one of the most important factor to success

My rule on Treatment Planning

Only treatment plan and execute implant treatment as you would for your own family members.

Improper use of number and location of dental implants for final prosthesis

Lack of understanding of Biomechanical rationale requirements for functional loads

Biomechanical rationale

Definitions

• • • • • • •

Bone Remodeling-

internal restructuring of previously existing bone.

turnover or It is a coupled tissue level phenomenon.

Activation- of osseous precursor cells.

Active Resorption.

Reversal or Quiescence.

Formation

Remodeling cycle called “Sigma”- in humans is 17 Weeks.

Definitions

•

Strain-

the change in length divided by the original length and the units of strain are given in percent.

• Too much bone strain at the implant interface causes bone loss.

• The strain to bone may be caused by the stress applied to the prosthesis.

Stress = _____

Mechanism of Implant Failure

Occlusal overload Microdamage Increased bone remodelling rate Histological change in bone at implant interface and adjacent bone Increased effect of magnitude of strain

Stress Factors

•

Excess stresses to an implant / bone interface will cause overload and implant failure.

• • • • • •

Complications from Stress: -implant integration failure with fibrous tissue formation around implant, mobility instead of rigid fixation.

-Early crestal bone loss.

-Occlusal overload bone loss -Screw loosening (prosthesis or abutment) -Implant fracture (body or component) -Prosthesis fracture (occlusal material or framework)

5) Clinical Force factors

• • • • • • • • •

1) Bite Forces (light vs. normal vs. heavy) 2) Parafunction 3) Crown implant height ratio 4) Masticatory Dynamics 5) Opposing Arch 6) Direction of load 7) Nature of Opposing Arch 8) Position of Abutment in the arch 9) Occlusal scheme

1) Bite Forces (light vs. normal vs. heavy)

• Implant supported Fixed Prosthetics > • Implant supported Removable Prosthetics > • Natural dentition with Porcelain Prosthetics > • Natural dentition > • Partial Removable Prosthetics > • Full Removable Prosthetics

2) Parafunction

Repeated or sustained non-functional wear that is harmful to the stomatognathic system.

–

A) Bruxism- vertical or horizontal nonfunctional grinding of teeth. A maximum bite force recorded at 990 psi (4-10 times normal)

–

B) Clenching- a habit that generates a constant force exerted form 1 occlusal surface to the other without any lateral movement. Bruxing and clenching can exist in combination.

–

C) Tongue Thrust and Size- unnatural force of the tongue against the teeth during swallowing.

Character Of Forces

• A) Force Magnitude (heavy, medium, light) • B) Force Duration • C) Force Type (Compressive, tensile, shear) • D) Force Direction • E) Force Magnifiers (Horizontal and vertical cantilevers)

Surface Area for maximal Bone / implant interface contacts

Options To Increase Surface Area

• 1) Increase Implant Numbers • 2) Increase Implant Size and Length • 3) Implant Design • 4) Implant Surface conditioning • 5) Bone Density

1 ) 2) 3) Surface Area for maximal Bone / implant interface contacts.

Maximize implant number.

Maximize implant diameter.

Maximize implant length.

(Without violation of the limits of bone volume or anatomical structures.) 4) Bone Density Classification D1- Dense cortical ( > 1250 Hounsfield units) D2- Porous cortical and coarse Trabecular ( 850-1250 H. units) D3- Porous cortical (thin) and fine Trabecular (350-850 H. units) D4- Fine Trabecular (< 150 H. units)

Goals of Diameter Of Implant

Increase surface area Compensate for unfavorable patient bite force factors Minimize cantilevers for angled implants Compensate for poor bone density Enhance surface for shorter implants Improve emergence profile Decrease screw loosening Minimize component fracture Facilitate oral hygiene

Approximate Surface Area Of Anterior Natural Dentition (mm2)* Position Central Lateral Cuspid Maxilla 204 179 273 Mandible 154 168 268

•

Jepsen, A root Surface Measurement and a Method for x ray determination of Root Surface, Acta Odontol., Vol.21:35, 1963

Approximate Surface Area Of Posterior Natural Dentition (mm2)* Position First Premolar Second Premolar First Molar Maxilla 234 220 443 Mandible 180 207 431

•

Jepsen, A root Surface Measurement and a Method for x ray determination of Root Surface, Acta Odontol., Vol.21:35, 1963

Goals of Length Of Implant

1. Increase surface area 2. Compensate for unfavorable patient bite force factors 3. Gain initial ridged fixation of dental implant 4. Compensate for poor bone density 5. Not violate any vital anatomical anatomy (IAN, mental nerve, sinus, lingual concavities, nasal foramen, adjacent roots, etc….)

Failure

•

Poor Bone Site Selection Short, Narrow, Porous

•

Implant Design Oversized implant

•

Poor Surgical Technique

•

Poor Prosthetic Technique

•

Poor Patient Cooperation

Success

•

Bone Site Selection High, Wide, Dense

•

Implant Choice/Design Bone around implant

•

Surgical Technique Proper implant placement Adequate healing time Sterile technique

•

Prosthetic Reconstruction Biomechanical design Occlusal relationships

•

Patient Hygiene / Recall

Classification Of Oral Implant Failures

• 1) Biological:

•

A) Early or Primary (before loading): Failure to establish osseointegration.

•

B) Late or Secondary (after loading): Failure to maintain the achieved osseointegration.

Early or Primary (before loading): Failure to establish osseointegration .

• 1) Inadequate quantity and quality of bone for initial fixation of dental implant.

• 2) Experience of surgical operator.

• 3) Over heating of bone during osteotomy preparations.

• 4) Pressure necrosis, especially in D1 bone.

• 5) Infection operatively after initial surgery.

• 6) Incision line opening leading to complications or infections.

Goodacre C, JPD 2003

Classification Of Oral Implant Failures

• 2) Mechanical:

•

Fracture of implants, connecting screws, bridge frameworks, coatings, porcelain, etc….

Goodacre C, JPD 2003

Iatrogenic

1) Treatment planning flaws and complications.

2) Violation of vital anatomical structures.

3) Inappropriate application of procedure to site requirement.

4) Compromised surgical skills.

5) Compromised prosthetic skills.

Types of Surgical Complications

A) Surgical complications B) Hemorrhage-related complications C) Neurosensory complications D) Mandibular fracture E) Adjacent Tooth devitalization F) Life-Threatening hemorrhage G) Air Emboli H) Violation of Mandibular canal I) Aspiration of screwdriver, parts, components

Surgical Parameter by REGIONS Posterior Mandible

•

D2 – D3 bone density 1) Problem: Mandibular nerve location.

•

Solution: Surgical landmark to be at least 2.0 mm above the mandibular canal to establish a surgical zone of safety.

•

Pre-surgical diagnostic workup to measure allowed length of implant. Use of periapical and panoramic x-rays, tracings, CT scans to verify length.

•

Surgical use of directional guide pins to verify proximity to mandibular nerve after initial pilot osteotomy.

•

Remember: “ The enemy of good is perfection.

” If in doubt, use shorter implant lengths ( at least 10.0 mm)

Posterior Mandible

Factors to Consider in Zone

Damage to Inferior Alveolar Nerve (IAN)

Potential Complications

Paraesthesia Damage to Mental nerve

Treatment Options

Surgical landmark to be at least 2.0 mm above the mandibular canal to establish a surgical zone of safety Use of Periapical and panoramic x-rays, tracings, CT scans to verify length.

Surgical use of directional guide pins to verify proximity to mandibular nerve after initial pilot Osteotomy.

Surgical Parameter by REGIONS Posterior Mandible

•

2) Problem: Lingual concavity and angulation flare of posterior mandible.

Solution: Use of CT scans to perform electronic surgery as part of treatment planning. Minimal reflection of lingual flap to visualize lingual wall of bone trajectory. Implant length to meet biomechanical requirement without anatomical violations.

Posterior Mandible

Factors to Consider in Zone

Perforation of Lingual concavity

Potential Complications

Profuse uncontrollable bleeding

Treatment Options

Use of CT scans or tomography films identify anatomical concavity Damage to Lingual nerve Surgical use of directional guide pins to verify angulation Reflection of flap to palpate and measure concavity undercut

•

Contraindications to posterior single –tooth implant

3) Inadequate bone volume –

•

Width-consider grafting or alveloplasty or implant placement with guided bone regeneration.

•

Length- Mesialdistal, intratooth space, need >7 for a 4.0mm implant with 1.5mm between implant and adjacent tooth.

•

Height- no treatment, shorter implants, or particulate grafting of exposed threads.

Posterior Mandible

Factors to Consider in Zone

Inadequate Width of Buccal bone volume

Potential Complications

Buccal threads of implant exposed

Treatment Options

GBR technique to graft buccal aspect after implant stability achieved Soft tissue irritation Continuous lost of buccal plate after functional loading Alveoloplasty of platform to gain width and interocclusal space Use of smaller diameter implant to accept compromise (>4.0 mm)

Posterior Mandible

Factors to Consider in Zone

Inadequate Height of vertical bone volume

Potential Complications

Violation of IAN Increased crown / implant ratio with increased vertical cantilever

Treatment Options

Use of shorter implants No treatment for implants with “ shorten dental arch concept ” GBR of vertical exposed threads (unpredictable) Angulated implants Nerve Repositioning

Surgical Parameter by REGIONS Anterior Maxilla

Position of Implant placement in 3 DIMENSION

Buccal / Palatal Position:

Implant platform to be at INCISAL EDGE with 1/3 buccal to edge and 2/3 palatal to edge of adjacent teeth.

Mesial / Distal Position:

1.5-2.0mm between implant and adjacent tooth, 3.0mm between 2 adjacent implants.

Apical / Coronal Position:

Implant platform to be 3.0 mm apical to free gingival margin of adjacent teeth or ideal position.

Implant Position Related To Retention Mechanism

Cement retained

Buccal / Palatal Position:

Implant platform to be at INCISAL EDGE with 1/3 buccal to edge and 2/3 palatal to edge of adjacent natural dentition.

Screw retained

Buccal / Palatal Position:

Implant platform to be at CINGULUM aspect relative to adjacent natural dentition.

Maxillary Anterior

Factors to Consider in Zone

Exact implant position placement requirement for HIGHLY esthetic demanding prosthetic results

Potential Complications

Too Shallow placement leads to interface showing Soft tissue thin biotype recession risks

Treatment Options

Placement of implant platform to level of 3.0 mm apical to adjacent free gingival margin Use of screw retain due to lack of interocclusal space Compromised emergence profile

Maxillary Anterior

Factors to Consider in Zone Potential Complications Treatment Options

Exact implant position placement requirement for HIGHLY esthetic demanding prosthetic results Too Deep placement leads difficulty in cement clean up Creation of deep soft tissue pocket inaccessible by oral hygiene aids Use of screw retain to avoid need for cement Use of custom abutment to raise level of desired margin of crown for cement option Use of pre-mucosal extensions (PME) abutments to raise crown margin

Maxillary Anterior

Factors to Consider in Zone Potential Complications Treatment Options

Exact implant position placement requirement for HIGHLY esthetic demanding prosthetic results Too Buccal placement will lead to inappropriate emergence profile of prosthetic crown Avoid by use of Lindenman drill to counteract dense palatal bone Use of customized UCLA abutment to offset poor angulation Buccal bone with potential dehiscence and soft tissue recessions Use of screw retained crown with access hole through facial aspect Remove implant

Maxillary Anterior

Factors to Consider in Zone Potential Complications

Exact implant position placement requirement for HIGHLY esthetic demanding prosthetic results Too Palatal placement will compromise lingual bulk of final prosthesis Potential phonetic interferences

Treatment Options

Screw retain prosthetic implant crown Use of customized UCLA abutment to correct emergence profile Creation of ridge-lap over buccal aspect Removal of implant Potential violation of incisive foramen/canal

Palatal placement requires ridge lap and compromised phonetics

Surgical Parameter by REGIONS Anterior Mandible

• •

D1-D2 bone density 1) Problem: Overheating during osteotomy preparations.

–

Solution: Prepare osteotomy with constant pumping motion and use higher torque speed. Use new drills with copious COOLED irrigations and incremental drill sequence.

•

Surgical Parameter by REGIONS Anterior Mandible

2) Problem: Pressure necrosis of devital zone of bone around implants. (Early signs of RL around implants during healing with symptoms of pain to patient.)

•

Solution: Must bone tap with hand ratchet each osteotomy site prior to surgical implant placement. Reverse torque final implant position by 1/4 - 1/2 turn to relieve internal stresses and pressure.

Maxillary Anterior

Factors to Consider in Zone

Dense D1 bone density

Potential Complications

Overheating of bone causing bone necrosis Over pressure of bone causing pressure necrosis of devitalized bone around implant

Treatment Options

Prepare with high torque speeds Use new sharp drills Copious cooled saline irrigation with pumping motion Use specialized dense bone drills Bone tap prior to implant placement ¼ back turn of final implant position to release stress

• • • • • • •

Surgical Technique Specific For D1-D2 Bone Types 1) Use new and sharp drills for osteotomies.

2) Use chilled saline with internal and external copious irrigation.

3) Use “ Pumping ” motion to allow osteotomies to cool down between advancement in depth.

4) Use marginal enlargement of osteotomies with sequential drill sizes.

5) Must bone tap prior to implant placement.

6) After initial implant placement, reverse torque implant by ¼ ½ turn.

7) Can consider immediate or early loading.

Surgical Parameter by REGIONS Anterior Mandible

•

3) Problem: Resorption pattern of anterior mandible resulting with lingualized implant angulations and position.

•

Solution: Fabrication of Surgical guides from approved wax up of final prosthesis. May need to compromise with thicker amount of lingual acrylic.

Surgical Parameter by REGIONS Anterior Mandible

• •

4) Problem: Resorption pattern or anatomical pattern resulting in steep lingual concavity.

Solution: Pre-surgically diagnose situation with use of lateral ceph radiographs or CT scans. Surgical reflection of lingual flap with direct vision inspection and instrument protection.

Resorption pattern

Anterior Mandible

Factors to Consider in Zone

Perforation of Lingual concavity

Potential Complications

Profuse uncontrollable bleeding

Treatment Options

Use of CT scans or tomography films identify anatomical concavity Damage to Lingual nerve and artery Surgical use of directional guide pins to verify angulation Reflection of flap to palpate and measure concavity undercut

•

Surgical Parameter by REGIONS Anterior Mandible

5) Problem: Location of Mental foramen with or without anterior loop.

Solution: Locate the mental nerve by anatomical location relative to the face. Vertical line through pupils of the patient ’ s eyes passes through infraorbital and mental foramen. Finger width lateral to ala of the nose also is on this vertical landmark.

Surgical dissection to identify and locate the mental nerve with safety zones marked.

Anterior Mandible

Factors to Consider in Zone Potential Complications

Location of mental foramen and nerve Paraesthesia to innervations supply of mental nerve

Treatment Options

Identify the mental foramen and provide zone of surgical safety of >3.0 mm Surgical reflection to identify and protect mental foramen and contents

Surgical Parameter by REGIONS Posterior Maxilla

Surgical Parameter by REGIONS Posterior Maxilla D3-D4 bone density: 1) Problem: Violation of Maxillary Sinus Solution: Determine need for sinus augmentations prior to implant placement.

Need minimal of 5.0 mm of autogenous recipient bone for simultaneous implant placement with sinus graft.

Posterior Maxilla

Factors to Consider in Zone

Compromised height due to violation of maxillary sinus

Potential Complications Treatment Options

Radiographs, CT scans to determine treatment plan to manage lack of height Sinus augmentations Angulated implants Short implants No Treatment and utilize “ shorten dental arch concept ”

Surgical Parameter by REGIONS Posterior Maxilla

•

2) Problem: Bone density with least implant contact (50%).

Solution: Use a bone condensing (osteotomes) rather than bone removing (osteotomies) technique for implant site preparations.

Posterior Maxilla

Factors to Consider in Zone

D3, D4 bone type, least density of all

Potential Complications

Biomechanical complications due to high bite force Posterior zone with high bite forces Least amount of bone implant contact (BIC)

Treatment Options

Don ’ t use final drill size for desired implant diameter to use compressive forces of implant insertion into smaller Osteotomy Use of tapered implant design or aggressive thread design (Nobel Active Implant) Extend healing periods

Implant Prosthetic concepts

Implant Prosthetic Concepts 1) Minimize ( < 3 units ) number of pontics.

2) No Cantilevers (especially distal) 3) No Connection to natural teeth.

4) Splinting of implant crowns.

5) Minimize facial / lingual occlusal table.

6) Implant protected occlusal scheme.

7) Progressive bone loading concept on softer bone.

Splinting of implant crowns

Don’t Do This!

4) Occlusal load axial to implant body angle

5) Low cusp angle of crowns

7) Cantilever or offset distance ( Horizontal offset)

Indications For Open Tray Impression Technique

1) Require adequate access for prosthetic open tray impression copings. (Anterior regions of mouth.) 2) Multiple units to register accurate relationship by indexing of impression copings.

3) Allow impressions with Divergent angulated dental implants.

4) Usually require custom impression trays or altered disposable trays.

5) Must verify seating with radiograph 6) Consider indexing with resin pattern

Indications for Closed Tray Impression Technique

1) Require minimal access for prosthetic closed tray impression copings. (Posterior regions mouth.) 2) Single or quadrant units.

3) Allow impressions with Parallel alignment of dental implants.

4) Usually require stock impression trays or disposable trays.

5) Must verify seating with radiograph.

6) Plug screw hole to avoid positive impression registration

• • • • • • • • • •

Implant Protected Occlusion

1) No premature occlusal contacts or interferences. Timing of occlusal contacts protected by natural dentition.

2) Influence of surface area 3) Mutually protected articulation (No lateral excursion) 4) Occlusal load axial to implant body angle 5) Low cusp angle of crowns 6) Crown Height (vertical offset) 7) Cantilever or offset distance ( Horizontal offset) 8) Implant crown contour (narrow B /L dimensions) 9) Selection of occlusal materials 10) Verify implant supported prosthesis have lightened occlusion where shim stock (12 um) pulls through in C.O. or M.I.P.

Implant Protected Occlusion

The Maintenance Requirement

1) Post insertion 1 week later- verification of soft tissue health and implant protected occlusion 2) Post insertion follow up every 4 months for the first year after loading of prosthesis verification of crestal bone changes with radiograph, soft tissue health and implant protected occlusion 3) Post insertion follow up every 6 months for the second year and beyond.

3) Prosthetic Parameters:

Biomechanical rationale Implant Prosthetic concepts Implant provisionalization options Open versus Closed tray impression Screw versus cement retention Implant protected occlusion Management protocol for parafunctional habits Management Options For Compromised Interocclusal distance

Management protocols specific for patients with parafunctional habits

Force Factors

1) Magnitude (light, normal, heavy) 2) Duration (day time, night time) 3) Frequency (number / unit time) 4) Direction (vector of forces) 5) Type (compression, tensile, shear) 6) Magnifiers (height, cantilevers, parafunctional habits) 6) Combination

Strategies To Manage Parafunction Forces 1) Educate patient of parafunctional habits.

2) Placing increased number of implants.

3) Placing larger diameter implants.

4) Placing implants in positions to reduce bending overload or positions to promote axial loading.

5) Avoid use of cantilevers or pontics.

6) Use bruxism night guard appliances.

7) Increasing time intervals during prosthetic restoration stages for progressive loading protocol.

8) Paying diligent attention to occlusal contact design for “Implant Protected Occlusion” and axial loading.

9) Alter occlusal material of prosthetic teeth to be acrylic resin for removable prosthesis and metal occlusal for fixed prosthesis.

Incidence Rate Of Mechanical Complications

1) OD loss of retention or adjustments 30% 2) Resin acrylic veneer facture of FPD 22% 3) OD relines required 4) OD clip / attachment fractures 19% 17% 5) Prosthesis screw loosening 6) Abutment screw loosening 7% 6%

Implant Prosthetic Complications Complication Etiology Solution OD loss of retention or adjustments (30%) Lack of Simultaneous contact engagements of attachments with differential wearing of component parts Pick up attachments to be parallel Use customized abutments to correct for unparallel implant placements

Implant Prosthetic Complications Complication Etiology Solution Acrylic Fractures Inadequate interocclusal distance from implant platform level to opposing cusp Osteoplasty prior to implant placement to increase interocclusal distance Consider different attachment options that require less interocclusal distance (Locator attachments) Need >2.0 mm acrylic resin thickness over attachments for strength

• • • • • •

Space Requirements for Bar-Overdenture -Thickness of soft tissue -Hygiene space under bar -Thickness of bar -Clip and housing -Acrylic denture base -Denture tooth 2.0 mm 1.5 mm 4.0 mm 1.5 mm 2.0 mm 3.0 mm

•

Total Height Requirement =14.0 mm

•

Compromised Height is 10.5-14.0 mm (bar touching soft tissue, reduce thickness of bar, attachment type altered, reduce thickness of acrylic base and denture tooth size.

Implant Prosthetic Complications Complication Etiology Solution Porcelain Chips and Fracture Resin acrylic veneer fracture of FPD (22%) Unsupported substructure Heavy occlusion for implant restoration Steep cusp angles with lateral excursion forces Substructure extension to support porcelain of less than 2.0 mm thickness Confirm implant protected occlusion Shallow cusp angles with narrow occlusal table to avoid lateral forces

Implant Prosthetic Complications Complication Etiology Solution Porcelain Chips and Fracture Inadequate interocclusal clearance for abutment, substructure and porcelain Treatment plan options to manage interocclusal distance Screw retain option Metal occlusal Zirconia with higher incidence of porcelain shear fractures Osteoplasty prior to surgery to submerge implant platform level

Inter-Occlusal Space Recommendations

•

1) < 3.0 mm abutment height- Use screw retention.

•

2) 3.0-4.0 mm abutment height- Use screw retention or vary cement type to make non-retrievable.

•

3) > 4.0 mm abutment height- Use retrievable cement.

Implant Prosthetic Complications Complication Etiology Solution OD relines required (19%) Increased forces compared to conventional CD Increased use and forces applied to residual ridge areas with increased resorption Need relines in bilateral residual ridge resorption areas to provide load bearing areas of OD

Incidence Rate Of Mechanical Complications

Implant Prosthetic Complications Complication Etiology Solution Attachment breakage or fractures (17%) Improper loading, angulated and/or imbalance of engagements of attachments Differential wear of attachment parts Soft tissue support adequate for loading bearing areas of OD Pick up attachments after correction of imbalance and obtain parallel alignment of attachments and achieve simultaneous contacts of components Inadequate interocclusal distance Treatment plan properly Change attachment types that require less interocclusal distance

Broken Attachments Plastic bar clip

–

damaged or broken

•

cut along long axis with sharp knife and remove.

–

Missing

•

replace by inserting a new clip into denture base receptacle

•

if unavailable, contact Command Implant Coordinator

Broken Attachments Metal bar clip

–

damaged or broken (replacement clip available)

•

remove the clip and perforate the denture base carefully for intraoral pick up replacement.

• •

Block out under the bar with wax, seat the denture and position a new clip through access in denture base.

Use autopolymerizing acrylic resin with “bead brush” technique to fill in access and connect clip to denture base. Polish , disinfect and deliver.

•

Always confirm seating of denture after repair and evaluate occlusion.

Broken Attachments

•

Metal bar clip

–

Damaged or broken (replacement clip not available)

• • •

remove all remnants of the clip from the denture base.

block out under the bar with wax reline the clip area of the denture with a resilient chair side reline material (viscogel).

–

Intact clip with no retention

•

carefully bend the leaves of the clip toward the bar with a thin instrument.

• •

Reseat the denture to confirm increased retention.

Recheck occlusion.

Broken Attachments

•

Stud attachments

–

treatment is similar to clips

• •

tease out “O” ring with an explorer and replace as needed.

Fractured housing can be treated like a clip replacement.

Implant Prosthetic Complications Complication Etiology Solution Abutment Screw loosening (7%) Inadequate Preload forces applied to abutment screw with inadequate torque force Confirm proper use of torque driver, new abutment screw insert for each case, repeat torque tightening 2X with torque driver to 35Ncm.

If cemented crown, consider drilling access screw hole and convert to screw retained instead of fabrication of new crown

Problems with Screw Loosening

1) Improper use of torque driver leading to inadequate “preload” force application 2) Stripped screw driver or screw head 3) Use of lab screws versus definitive screws 4) Material and surface used for fabrication of screws 5) Design of screws 6) Occlusal overload 7) Combination of any or all of the above

Implant Prosthetic Complications Complication Etiology Solution Adjacent natural tooth drifting and opens contacts Viscoelastic nature of PDL with adjacent rigid fixation of dental implant Confirm implant protected occlusion Modification of adjacent occlusion to natural dentitions to prevent distal or mesial shifting of forces when partial edentulous space is present

Implant Prosthetic Complications Complication Etiology Solution Improper implant placement of implants to support desired prosthetic goals Improper treatment planning Surgery conducted without prosthetic goals Customized or angulated abutments Screw retained prosthesis with access holes to accommodate off angles Improper or lack of use of surgical guides Removal of implants and start again

Treatment Options when presented with minimal Interocclusal Distance 1) Increase vertical dimension of occlusion for restorative convenience.

2) Extract teeth involved that violated the interocclusal distance and replace accordingly.

3) Orthodontic intrusion of opposing teeth involved.

4) Coronoplasty, crown preparations, prophylactic endodontic therapy, periodontal crown lengthening options to restore teeth involved.

Treatment Options when presented with minimal Interocclusal Distance 5) Prior to surgical placement of implants, perform alveoloplasty of residual ridge to increase interocclusal distance.

6) Prosthetic design: screw retain as opposed to cement retain to implant level.

7) Restorative material: metal occlusal as opposed to porcelain fused to metal.

Lack of Inter Occlusal Clearance: Treatment Options

• 1) Coronal adjustment of opposing arch or prophylactic endodontic therapy, crown lengthening and crowns to opposing arch.

• 2) Alveloplasty prior to implant placement with deeper surgical implant placement.

• 3) Prosthetically compensate with screw retained and metal occlusal to decrease required restorative clearance.

Implant Prosthetic Complications Complication Etiology Solution Substructure misfits Impression copings not seated at final impression Verify with radiograph of confirmed seating Inaccurate final impression material unable to hold impression coping stable Use Medium body around impression coping or splinting with pattern resin Lab process errors during waxing, investing and casting Use experienced labs

Iatrogenic / Prosthetic

Need for Provisional Restorations:

– – –

Positional stability Occlusal function Easily cleaned and maintenance of oral hygiene

– – –

Nonimpinging soft tissues Strength and retention Esthetics

Iatrogenic / Prosthetic

Complication Etiology Solution Early soft tissue dehiscence Micro movement pressure to graft site Incorrect design of provisional restoration

Choose proper design of provisional restoration (fixed or removable) with proper relief over surgical site Apical pressure application to healing site - No provisional restoration

Removable Provisional

1) Acrylic RPD (flipper) a) Need proper design for occlusal stops.

b) Adequate relief under pontic site or above grafted site upon occlusal pressure.

c) Permanent soft tissue reline material as occlusal force buffer.

Removable Provisional

2) Essix appliance (Acrylic removable overlay prosthesis) a) Need proper design for occlusal stops.

b) Adequate relief under pontic site or above grafted site upon occlusal pressure.

c) Permanent soft tissue reline material as occlusal force buffer.

Removable Provisional

3) Hawley orthodontic retainer appliance: a) Need proper design of occlusal stops.

b) Adequate relief under pontic site or above grafted site upon occlusal pressure.

c) Permanent soft tissue reline material as occlusal force buffer.

Consequences of Peri-Implantitis

•

1) May lead to eventual implant loss.

•

2) Soft tissue exudates, abscess or infection localized to peri-implant locations.

•

3) Guarded prognosis and continuous soft tissue maintenance requirement for peri implant soft tissues.

•

4) Possible source of irritation and discomfort to patient.

Possible Etiologies of Peri Implantitis

• • • • • • • • •

1) Location of Microgap 2) Implant Thread Design 3) Surgical Trauma 4) Quality of bone 5) Occlusal Forces 6) Bacterial contamination 7) Biologic width consideration 8) Cement trap contamination 9) Combination of any / or all of above

Peri-Implantitis-Definitions

•

Defined as an inflammatory process affecting the tissues around an osseointegrated implant in function, resulting in loss of supporting bone.

(Albrektsson & Isidor 1994) •

Plaque-induced progressive marginal bone loss observed on radiographs with clinical signs of infection of the peri implant soft tissues.

(Cochrane Database of Systematic Reviews 2006)

Peri-implant Mucositis-Definitions

• Defined as reversible inflammatory changes of the peri-implant soft tissues without any bone loss.

(Albrektsson & Isidor 1994)

Prevalence Rates

• Peri-implant Mucositis: 8-44% • Peri-Implantitis: 1-19%

Cement retained

1) Ideal aesthetics.

2) Questionable retrievability.

3) Retention require conventional fixed prosthodontic principles of CHS of >7.0 mm.

4) Ideal Implant placement to support prosthesis with use of straight or angulated abutments.

5) Ideal Occlusion or support over axially loaded ceramics.

6) Less requirements for passivity or lab costs.

7) Removal of cement subgingival may be compromised.

8) Depth of implant level placement should allow ease of cement clean up.

Cement Problems

•

Subgingival cement left after cementation acting as a foreign body reaction causing pathologic bony and soft tissue reactions.

Dr. Mark Lin’s Cementation Technique

1) Paint and coat OUTSIDE crown margins with Vaseline. Confirm lab provided 2 layers of die spacers on implant abutment or scanning of abutments.

2) Light coat of cement of choice into implant crown restoration.

3) Pump restoration “Up and Down” motion to release hydraulic pressure build in to allow thinning of cement layer.

4) Removal after setting with curettes and floss.

5) Soft tissue release may be required to confirm total removal of excess cement.

6) Verification of seating of abutment and crown to implant platform level and cement removal.

Screw retained

• 1) Compromised aesthetics.

• 2) Reliable retrievability. (Multiple or full mouth reconstructions.) • 3) Retention achieved with minimal CHS of < 7.0 mm using screw retention preload principles.

• 4) Accommodate compromised Implant placement to support prosthesis with use of custom or angulated abutments.

• 5) Compromised Occlusion or support over axially loaded compromised integrity ceramics.

• 6) More requirements for passivity or lab costs.

• 7) No cement clean up considerations.

• 8) Deep implant level placements.

• 9) Transitional provisionals with multiple units.

Problems with Screw Loosening

Oral Hygiene

•

calculus build up can cause areas of soft tissue

•

inflammation.

may result in progressive bone loss if left untreated.

Treatment

•

remove prostheses, check implants for mobility, retorque abutments.

•

perform maintenance cleaning on prosthesis and

•

abutments.

reinsert prosthesis with new screws, give oral hygiene instructions.

Maintenance and Recall

•

Annually

–

periapical radiographs should be taken to monitor the crestal bone levels. (crestal bone can be at the level of the first thread in one year with 0.1mm continued loss to approximately 1. 5 mm total bone loss)

–

remove and reinsert screw retained implant prostheses every 2 years unless indicated otherwise.

•

Replace prosthesis with new retaining screws if removed.

– –

Cemented restorations are usually permanent (nonretrievable).

Recall focus

•

Occlusion - verify there are no excursive contacts. Should not hold shimstock. Better to be out of occlusion

• • •

Oral hygiene - same requirements as for natural teeth.

Soft tissue health - periodontal probing for evidence of disease.

Screw joint torque - check for loosened screws (most common problem).

• •

Integrity of attachments - applies to overdenture / overpartials.

Stability of implants - must be stable (non mobile) to be successful

•

Maintenance and Recall

Screw retained prosthesis

–

Remove prosthetic retention screws

•

Screw access holes are usually sealed with a layer of cotton pellet, silicone plug or gutta percha the acrylic or composite resin.

• • •

Expose the screw by drilling carefully through the resin.

Remove the screw (slot or hex) with the appropriate screw driver.

Throat drapes are highly recommended.

–

Check for implant mobility and retorque abutments to 20 Ncm. (hand tighten as much as possible with finger abutment driver if no torque control device is available)

– –

Clean and polish abutments (Do not remove) Reseat restoration using new gold retaining screws.

•

Tighten screws as if doing nuts on the lugs of an automobile - place all screws back with minimal torque. Then work back and forth across the arch until all are tightened to 10 Ncm. (hand torque with appropriate hand screw driver if no torque controller is available)

• •

Maintenance and Recall

Screw retained prosthesis (cont.)

–

Temporary reinsertion

•

fill access holes with small cotton pellet and polyvinylsiloxane impression material or putty.

–

Long-term reinsertion

•

fill access hole with small cotton pellet over the head of the screw, followed by warm gutta percha and only 1-2 mm of acrylic or composite resin.

Cemented restorations

–

Single unit

•

usually nonretrievable and not removed for maintenance.

–

Multiple unit (usually not indicated)

•

carefully tap off with crown remover, check for mobile implants and retorque abutment screws.

•

Replace restoration with provisional luting media, and recheck occlusion.

Hygiene Aids

• • • • • •

Super - floss End tufted brushes Proxy brushes Tarter control dentrifices Mechanical instruments Peridex

Incidence Rate Of Mechanical Complications

Implant Prosthetic Complications Complication Etiology Solution Porcelain Chips and Fracture Inadequate interocclusal clearance for abutment, substructure and porcelain Treatment plan options to manage interocclusal distance Screw retain option Metal occlusal Osteoplasty prior to surgery to submerge implant platform level

If cemented crown, consider drilling access screw hole and convert to screw retained instead of fabrication of new crown

Problems with Screw Loosening

Problems in the field

• • • • • •

Fractured/loosened screws Fixture loss Poor oral hygiene Soft tissue reactions Broken attachments Fractured components

Problems in the field

• • • • • •

Fractured/loosened screws Fixture loss Poor oral hygiene Soft tissue reactions Broken attachments Fractured components

• • • •

Fractured or loosened screws Usually results in localized inflammation, loose restorations and discomfort.

–

First suspicion when patient complains of discomfort or loose implant.

Prosthetic gold retaining screws have either a slot or hex head.

Abutment screws require a hex abutment driver, large slot, hex or square driver.

–

Standard and conical (estheticone) abutments have a raised hex and require a wrench that fits over this hex.

–

All other abutment screws have the slot, hex or square depression inside the screw head.

Loose single tooth abutments are true emergencies. Continued rotation can risk rounding the corners of the hex on the implant, causing a loss in anti-rotation.

•

Fixture loss ( Must differentiate between “failing” and “failed”) Failing Implant

–

Clinical signs:

• • • •

progressive bone loss soft tissue pocketing and crestal bone loss bleeding on probing with possible purulence tenderness to percussion or torque forces

–

Causes:

•

overheating of bone at the time of surgery or lack of initial stability.

• • • •

Nonpassive superstructures inadequate screw joint closure functional overload periodontal infection (peri-implantitis)

Fixture loss

•

Failing Implant

–

Treatment:

•

Interim: remove prosthesis and abutments

– – – –

irrigate with Peridex ultrasonic and disinfect all components reinsert assuring proper screw torque recheck passive fit of framework and occlusion

•

Failed Implant

–

Clinical signs:

• •

Mobility

–

verify fixture mobility by removing any abutments and superstructures first.

A “Dull” percussion sound has been associated with a failed implant

•

Peri-implant radiolucency can be a radiographic finding

–

often this is not evident on an X-ray

Fixture loss

•

Failed Implant

–

Causes

•

surgical compromise (overheating bone and initial lack of stability).

• • • • •

Nonpassive superstructures.

Inadequate screw joint closure Too rapid initial loading Functional overload Periodontal infection (“peri-implantitis”)

–

Treatment

•

removal of the implant

Iatrogenic / Surgical

Complication Etiology Solution Block graft mobility during implant placement Inadequate final Osteotomy preparation in width and/or length for desired implant size Prepare Osteotomy site again to appropriate length prior to implant placement.

As a result the implant insertion protocol separates the block graft from recipient site Consider use of bone tap drills prior to implant placement.

2-stage surgery with increase healing time

Clinical Protocol Related Block Grafts (Symphysis)

• Easier surgical access • Larger donor graft size • Potentially thicker volume of donor graft • Mostly cortical with cancellous parts • More demanding for wound closure

Clinical Protocol Related Block Grafts (Symphysis)

Complication Etiology Solution Damage or devitalization of adjacent roots Not paying attention to surgical safety zone May require root canal therapies to devitalized roots of mandibular anterior dentition Superior aspect of bone harvest must be at least 5.0 mm away from root apex of mandibular incisors Surgical zone of safety to be 5.0 mm away from roots, mental foramen, protuberantia mentalis / inferior border of mandible

Clinical Protocol Related Block Grafts (Symphysis)

Complication Etiology Solution Disturbed changes to neurosensory perception or numb teeth during healing Harvest of graft resulted in disturbance of the neurovascular innervations to localized area Incidence rate of 29% Reassure patients that disturbance is transitional and should return within 3-6 months post operatively Altered sensation of mucosa or facial aspect of the lip or chin area

Clinical Protocol Related Block Grafts (Ramus)

• Difficult surgical access, especially inferior cut • Smaller donor graft size • Potentially thinner volume of donor graft • Mostly cortical with few cancellous parts • Easy wound closure

Clinical Protocol Related Block Grafts (Ramus)

Complication Etiology Solution Damage to inferior alveolar nerve Height of approximately 11 mm with width of approximately 14 mm Inferior and medial cut too deep and violation of neurovascular bundle of the IAN Prevention and knowing the anatomical boundaries Reassure patient that disturbance is transitional and should gradually return within 3-6 months

Clinical Protocol Related Block Grafts (Ramus)

Complication Etiology Solution Inadequate donor size harvest, too thin or too small Difficulty of surgical access Impaired visual access to inferior cut Soft tissue incision and reflection to access desired size of graft required Poor patient selection for Ramus harvest Use of additional site to complete desired size of graft

Iatrogenic / Surgical

Complication Etiology Solution

Block graft mobility during implant placement Insufficient healing time Lack of initial block stability If graft appears vital: remove it, revive the recipient site, reposition graft and reaffix with micro screws.

Wait at least 6 months of healing with no loading.

Dead space too large or granulation tissue interposed between donor and recipient site Micro movement of graft during healing from prosthesis loading If graft appears Non vital: Remove it, clean recipient site, consider another grafting procedure.

Bilateral Sinus Grafting

Iatrogenic / Surgical

Complication Etiology Solution Small Perforation (>5 mm) of the sinus Schneiderian membrane incidence rate of 10-35% Membrane is too thin specific to the patient Membrane separation too rapid or wrong instrumentation Presence of mucoid cyst Continue to separate around the small perforation to collapse and fold itself, then place a resorbable collagen membrane patch to close the breach integrity of membrane.

Presence of bony septae

Iatrogenic / Surgical

Complication Etiology Solution Large Perforation of the sinus membrane Membrane is too thin specific to the patient Membrane separation too rapid or wrong instrumentation Presence of mucoid cyst or Presence of bony septum -Continue to separate around the large perforation to collapse itself, then place a slow resorbable membrane patch to close the breach integrity of membrane.

Attempt to suture membrane Window opening with carbide instead of diamond burs -Abort procedure and reattempt entry after 6 12 months of healing.

During the Procedure

• Window Separation • Haemorrhage • Pus • Serous Fluid • Difficulties in Sinus Lining Elevation

Difficulties in Window Separation

• Cut not through Bone • Lower Cut below Floor of Sinus • Cut too far Anterior • Presence of Buttress • Laceration of Lining

Difficulties in Lining Elevation

• Buttresses • Undulations over Roots • Peduncles over Roots • Visibility and Access • Sinus Lining Tears

Cause of Lining Perforation

• During Periosteal Elevation • During Window Preparation • Inadequate Instruments • Buttresses

Lining Perforation Management

• Layering • Suturing • Abort

When Tear Occurs continue Elevation away from Tear

Suturing Tears

• Do NOT attempt to Suture Thin Fragile Linings • Larger Tears will occur

Immediately Post-operative

• Bruising • Haemorrhage • Swelling • Pain • Suture Line Opening • Infection

Delayed Post Operative

• Pain • Infection and Swelling • Acute Sinusitis • Chronic Sinusitis • Oral-Antral Fistula

During Implant Placement • Pus • Sterile Serous Fluid • Non-conversion of Graft • Sinus Lining Perforation

Late Complications

• Infection • Loss of Graft • Bone Loss around Implants • Loss of Implants

Causes of Complications

• Pre-existing Infection • Lining Perforation • Surgical Field Contamination • Graft Non-conversion • Patient Non-compliance

Patient Non-compliance

• Smoking • Drugs • Alcohol • Poor Oral Hygiene • Self Abuse

Surgical Field Contamination • Poor Surgical Technique • Contaminated Graft Material • Contaminated Implants

Clinical Protocol Related Sinus Augmentations Complication Etiology Solution Sinusitis Infection Perforation of the sinus membrane Prevention of tear in sinus membrane Antibiotic Prophylaxis Topical decongestants Avoidance of any action that creates +ve or –ve sinus pressure. Cessation of nose blowing and sneezing with open mouth

Iatrogenic / Surgical

Complication Etiology Solution Early soft tissue dehiscence, flap necrosis or premature incision line suture opening Suturing under tension -Suturing without tension Smoking habits Prosthesis loading Traumatic surgery Infection - by oblique release cuts or horizontal scoring and blunt dissection of periosteum inferior to mucogingival junction prior to suturing Insufficient vascularization

Iatrogenic / Surgical

Complication Etiology Solution Early soft tissue dehiscence, flap necrosis or premature suture opening Sharp edges to block bone graft or material causing dehiscence over thin soft tissues -Suturing without tension

Contour of block grafts to ensure smooth, rounded sides

Consider connective tissue grafting prior or in conjunction to block graft

Iatrogenic / Surgical

Complication Etiology Solution Early soft tissue dehiscence and flap necrosis Suturing under tension Smoking habits Prosthesis loading Traumatic surgery Infection Insufficient vascularization Suturing under tension Sharp edges to block bone graft or material causing dehiscence over thin soft tissues -Do not try to suture again -Rx: antibiotics, Chlorhexidine rinse -Induce marginal bleeding for healing by granulation tissue formation and secondary healing

Iatrogenic / Surgical

Complication Etiology Solution

Early soft tissue dehiscence, flap necrosis with membrane exposure Suturing with tension Smoking habits Prosthesis loading -

Do not try to suture again -Rx: antibiotics, Chlorhexidine rinse -Induce marginal bleeding for healing by granulation tissue formation -If infected, remove membrane with no replacement and expect partial loss of graft

Clinical Protocol Related Soft Tissue Grafts Complication Etiology Solution Incomplete root coverage with Free Gingival Grafts Improper classification of marginal tissue recessions Referral to Periodontist Inadequate root planing Failure to treat the planed root with citric acid Take additional C.E. courses with Drs. Pat Allen and Michael Pikos Inadequate size of interdental papillae Improperly prepared donor tissue

Clinical Protocol Related Soft Tissue Grafts Complication Etiology Solution Incomplete root coverage with Free Gingival Grafts Inadequate graft size Inadequate graft thickness Dehydration of graft Inadequate adaptation of graft to root and remaining periosteal bed Failure to stabilize the graft Referral to Periodontist

Clinical Protocol Related Soft Tissue Grafts Complication Etiology Solution Incomplete root coverage with Free Gingival Grafts Excess or prolonged pressure in coaptation of sutured graft Reduction of inflammation prior to grafting Referral to Periodontist Trauma to graft during initial healing Excessive smoking

Medical Status Psychological Status Smoking Effects Complications In Tissue Engineering Host / Patient Related Operator / Surgeon Related Clinical Protocol Related Iatrogenic Surgical Prosthetic Block Grafts Sinus Augmentations Soft Tissue Grafts

Advantages of Immediate Loading • Immediate patient rehabilitation with instant gratification by patients • Support and contours marginal soft tissues in esthetic zones • Stimulation of bone regeneration with progressive loading protocol • Decreased clinical interventions and appointments • Decreased treatment time / increase profit margin

Disadvantages of Immediate Loading • Increased cost due to provisional fabrications • Potential higher failure rate if inappropriately applied • Rely on patient cooperation and compliance for success • Need back up plan for provisional options

Indications to Immediate loading

• Primary surgical implant stability of >35 Ncm • Lower anterior zones with splinting • Patient driven for esthetic zones • Aid in soft tissue contouring during healing phase • Compliance of soft diet by patient during healing

Contraindications to Immediate loading

• Inadequate surgical initial stability of < 35 Ncm • Need for bone grafting to implant recipient site • Smokers • Periodontal disease • Poor prosthetic occlusal control of biomechanics • Poor patient compliance and cooperation

Indications for Flapless Surgery

1) Confirmed 3 dimensional anatomical bony recipient site for desired implant diameter, length and angulations.

2) Abundant keratinized attached soft tissue adjacent the buccal aspect of implant recipient site.

3) Adjustment to depth of drilling length with soft tissue thickness accounted during osteotomies.

Advantages for Flapless Surgery

1) Less discomfort and morbidity for patients 2) Minimal to no swelling or bruising after surgical procedure 3) No suturing or removal of sutures post surgical appointment

Disadvantages for Flapless Surgery

1) Blinded procedure without flap release 2) Cannot visualize, identify and protect important anatomical landmarks 3) Risk of bone fenestration and dehiscence not identified 4) Risk of perforations of bone and incorrect implant alignment 5) Experienced surgeons to attempt

Complication Management

1) Plan 2) Prepare 3) Prevent

Dr. Mark Lin’s Contact Information

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E-Mail address: [email protected]

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Office Number: 416-221-8828

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Personal Cellular number: 416-991-8828