The Biology of Dental Implants James Q. Swift, DDS Division of Oral and Maxillofacial Surgery University of Minnesota.
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The Biology of Dental Implants James Q. Swift, DDS Division of Oral and Maxillofacial Surgery University of Minnesota Concepts of Connective Tissue Healing Around Implants Osseous Integration / Osseointegration Fibrous Integration Fibro-osseous Integration Bone Healing Phase I: Inflammatory Phase Phase II: Proliferative Phase Phase III: Maturation Phase Phase I Bone Healing: Day 1-10 Absorption of plasma proteins Platelet aggregation and activation Clotting cascade activation Cytokine release Phase I Bone Healing: Day 1-10 Nonspecific cellular inflammatory response Specific cellular inflammatory response Macrophage mediated inflammation Phase II Bone Healing: Day 3-42 Neovascularization Differentiation, proliferation and activation of cells Production of immature connective tissue matrix Phase III Bone Healing: After Day 28 Remodeling of the immature connective tissue matrix with coupled resorption/ deposition of bone Bone remodeling in response to implant loading Physiologic bone recession Mucoperiosteal Healing Phase I: Inflammatory Phase Phase II: Proliferative Phase Phase III: Maturation Phase Phase I Mucoperiosteal Healing Inflammatory Phase: Day 1-10 Platelet aggregation and activation Clotting cascade activation Cytokine release Nonspecific cellular inflammatory response Macrophage mediated inflammation Phase II Mucoperiosteal Healing Proliferative Phase: Day 2-42 Neovascularization Differentiation, proliferation and activation of cells Deposition of immature collagen, elastin, and ground substance Phase III Mucoperiosteal Healing Maturation Phase: After Day 21 Connective Tissue Remodeling Bone Implant Interface Dependent on implant material Calcified bone, unmineralized osteoid matrix, and connective tissue Zone of amorphous material – Proteoglycans and glycosaminoglycans – 100-3000 angstroms Collagen filaments Chemical Bonds Between Bone and Implants van der Waals Local direct chemical bonds (ionic, covalent) Chemical bonding well described with calcium phosphate ceramics Some materials have no chemical bond but have excellent bone contact (CP titanium vs. HA) Factors Affecting Healing Surgical technique Premature loading Surgical fit Extraction sites Factors Affecting Healing Peri-implantitis Bone quality Staged healing Logic CONTROL 60 50 40 30 20 10 0 -10 0 200 400 600 800 3 Healing Groups Experiment Control 12 Pigs 6 Pigs Healing Healing 1 Month 1 Month 2 Month (4) 2 Month (4) (4) (4) 4 Month 4 Month (4) (4) 5 Months Controlled Loading 5 Months Non-Loading Radio-Subtraction (S3D, MDRCB One Month Healing Four Months Healing Micro-CT Images Four Months Two Months One Month Stevenel’s Blue and Van Gieson’s Picro-Fuchsin Four Months Two Months One Month Issues Relating to Physical Status of Recipient Nutritional status Age Hematologic issues Issues Relating to Physical Status of Recipient Diabetes Corticosteroids Radiation 51 year old man CC- “I ‘ve been referred for evaluation and treatment for a growth in my jaw” HPI – 2 month duration – mobile teeth – facial swelling 51 year old man PMH – Hypertension-well controlled PDH Imaging findings – 4 cm x 2 cm radiolucent lesion left mandibular body causing tooth displacement 51 year old man Problem – – – – – list Radiolucent lesion Teeth vital Buccal plate perforation No paresthesias Differential diagnosis ameloblastoma central giant cell lesion odontogenic myxoma 51 year old man Treatment plan – Incisional biopsy for histologic typing – Prosthodontic consultation – Definitive imaging (CT scan) Biopsy results – Acanthomatous ameloblastoma 51 year old man Treatment – Arch bars/surgical stent construction – Transcervical approach for exposure and lateralization of IAN/Mental nerve – Transoral marginal resection preserving inferior border – Reconstruction plate applied for stabiliation 51 year old man Treatment – Healing interval 6 weeks – Mandibular reconstruction of 4cm x 2cm x1.5 cm defect with transcervical approach and AICBG (PCMB) – Healing interval 3 months 51 year old man Treatment – Placement of 5 osseointegrated dental implants left parasymphysis and body with prosthodontic guidance – Transoral removal of reconstruction plate – Healing interval 5 months 51 year old man Treatment – Second stage implant surgery with temporary healing abutments placed and preservation of attached gingiva – Prosthodontic reconstruction with fixed detachable prosthesis 51 year old man Results – Minimal paresthesia – No recurrence of lesion – Fixed prosthesis with lip support and excellent masticatory function 51 year old man Rationale for treatment – Alternative reconstructive surgery harbors greater potential morbidity – Fixed partial denture not ideal span too great – Removable partial denture not ideal blunting of vestibular and sulcular depths 16 year old woman CC- “I was in a car accident and hit the steering wheel.” HPI – Patient referred from emergency department – Injury had occurred > 16 hours prior to presentation – No other injuries identified (C-spine negative) 16 year old woman PMH – Non contributory PDH – Had just completed orthodontic therapy and was in retention phase 16 year old woman Clinical – – – – findings Lip laceration # 6 , 7 and 8 not visible Palpable step defect of alveolus Coagulum in socket sites of 6 & 7 16 year old woman Imaging – – – – findings #6 & 7 superiorly displaced and rotated #8 absent 9 abnormalities in the PDL Radiolucent transverse fracture line superior to apices of anterior teeth 16 year old woman Diagnosis – Trauma to the anterior maxilla Lip abrasion/ laceration Maxillary alveolar fracture Avulsion # 8 Traumatic displacement # 6, 7, & 9 Incisal edge fractures # 6, 7 & 9 16 year old woman Treatment – IV sedation – Surgical exploration of injured area with preservation of alveolar bone – Reduction of alveolar fractures – Repositioning of #6, 7 & 9 into normal dental arch relationship and stabilization with splint and pontic placed – Closure of laceration and surgical wound 16 year old woman Treatment – Referral to orthodontist Replaced stabilization wire with arch wire – Referral to endodontist RCT #6&7 16 year old woman Referral to prosthodontist – Consultation for dental reconstruction – Options FPD RPD Implant # 8 area 16 year old woman Treatment – After stabilization for 4 months Implant inserted # 8 area (internal hex) Presevation of attached tissue Preservation of bone Osteotome technique 16 year old woman Treatment – Integration time 5 months – Second stage surgery with preservation of soft tissue – Temporary healing abutment and temporary crown – Implant crown constructed 16 year old woman Results – Acceptable cosmetic outcome Rationale for treatment – Preservation of natural teeth, bone and soft tissue – FPD would require preparing endodontically treated adjacent teeth with uncertain prognosis – Patient and parents desires Thank you