The Biology of Dental Implants James Q. Swift, DDS Division of Oral and Maxillofacial Surgery University of Minnesota.
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Transcript The Biology of Dental Implants James Q. Swift, DDS Division of Oral and Maxillofacial Surgery University of Minnesota.
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