CONTENTS: INTRODUCTION PRE-TREATMENT EVALUATION A.Clinical Diagnosis B. Model Analysis C. Ridge Evaluation Spacing D.Radiographic Evaluation E.

Bone quality evaluation CONTROL OF ACTIVE DISEASES Pre-implant surgeries: 1)Frenectomy 2)Sinus floor augmentation 3)Socket preservation 4)Ridge augmentation and ridge reconstruction 5) Nerve repositioning surgery SUMMARY REFERENCES

INTRODUCTION:
A dental implant is a "root" device, usually made of titanium, used in dentistry to support restorations that resemble a tooth or group of teeth to replace missing teeth.Virtually all dental implants placed today are root-form endosseous implants, i.e., they appear similar to an actual tooth root (and thus possess a "root-form") and are placed within the bone (endo- being the Greek prefix for "in" and osseous referring to "bone"). The bone of the jaw accepts and osseointegrates with the titanium post. Osseointegration refers to the fusion of the implant surface with the surrounding bone. Dental implants will fuse with bone, however they lack the periodontal ligament, so they will feel slightly different than natural teeth during chewing. 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. They can also be used as anchorage for orthodontic tooth movement. The use of dental implants permits undirectional tooth movement without reciprocal action. In order to provide patients with strong implants, it is necessary to follow a sequence of steps: 1. PRE-TREATMENT EVALUATION A. Clinical Diagnosis B. Model Analysis C. Ridge Evaluation for Spacing 1. Radiographic Evaluation of Bone Quality and density 2. CONTROL OF ACTIVE DISEASES 3. PRE-implant SURGERIES: A. Frenectomy B. Sinus floor augmentation C. Socket preservation D. Ridge augmentation and ridge reconstruction E. Nerve reposition surgery

1. Pretreatment evaluation
It is the obligation of the dentist, to himself and to his patient, to acquire an adequate pre-treatment evaluation. The few minutes the dentist spends towards this end may prevent a medical emergency in the dental office and avoid potentially unpleasant and dangerous situations. The first series of questions are generaland straightforward. With today's emphasis on medical care, more people are awareof their conditions and are able to expoundupon their general state of health or explain why they are under a physician's care.This alone warns the dentist of any specialtreatment needed to avoid aggravating thecondition and prevents a crisis in the dentalchair. Patients should be assessed on their:
1. Medical and systemic health-related issues

2. Psychological and mental conditions 3. Habits and behavioral conditions 4. Oral status

A.Clinical Diagnosis
1) Medical and Systemic Health-Related Issues
i. Diabetes Mellitus A metabolic disease that can have significant effects on the patients ability to heal normally and resist infections. Poorly controlled diabetics often have impaired wound healing and a predisposition to infection. None of the studies conducted are able to correlate age, gender, smoking, diabetes type or level of diabetic control with implant failure. In a meta-analytical review of implant failures in nondiabetic patients, the early implant failure rate was 3.2% and the late implant failure rate 5.2%. The finding that diabetic patients experience slightly more late failures may be related to less tissue integrity caused by reduced tissue turnover and impaired tissue perfusion. These results suggest that diabetes may be a risk factor for implants, particularly for late failures. However, the risk does not appear to be particularly high.

ii. Bone Metabolic Disease Osteoporosis is a skeletal condition characterized by decreased mineral density. Primary osteoporosis has been attributed to menopausal changes (type I), age-related changes (type II) or idiopathic causes (type III) Secondary osteoporosis has been attributed to many different diseases and conditions, including diabetes, alcoholism, malnutrition and smoking. All the various types of osteoporosis share the same fundamental problem of decreased bone mineral density, and the concern that this condition may impair the patients ability to achieve and maintain implant osseointegration.

ii. Immune Compromise and Immune Suppression Individuals undergoing chemotherapy or taking medications that impair healing potential (eg.steroids) are probably not good candidates for implant therapy because of the effects on normal healing. A lowered resistance to infection may also be problematic for these patients. Likewise, patients with an immunocompromising disease, such as HIV or AIDS, are probably not good candidates for implants, especially when their immune system is seriously impaired. A past history of chemotherapy or immunosuppressive therapy may not be a problem if the patient has recovered from the side effects of treatment. ii. Radiation therapy Patients with a history of radiation treatment to the head and neckregion may not heal well after surgery. Soft tissue dehiscence may follow surgical manipulation, which may lead to osteoradionecrosis. Several studies have documented poor success rates for implants in patients with a history of radiation therapy.

1)

Psychologic and Mental Condition

Contraindicated because of patients uncooperativeness, lack of understanding, or behavioral problems. Physiologically, there is no reason to support that implants could not become osseointegrated in these patients. However, the patients ability to tolerate the number and type of treatment appointments required for implant placement, restorations and maintenance could be problematic. Exception might be individuals who demonstrate good cooperative behavior with only mild psychologic or mental impairment.

2) Habits and Behavioral Considerations

i. Smoking and tobacco use Moderate to heavy smoking has been documented to result in higher rates or early implant failure and adversely affect the long term prognosis of dental implant restorations. Smoking cessation may improve the success rate of implants. Parafunctional habits Such as clenching or grinding of teeth, has been associated with an increased rate of implant failure. Patient should be advised about an increased risk of complications or failures as a result of their clenching or grinding. Many consider bruxism to be a contraindications to implant treatment, especially in the case of short-span, fixed partial denture or a singletooth implant. If implants are planned for a patient with parafunctional habits, protective measures should be employed, such as creating a narrow occlusal table with flat cusp angles, protected occlusion, and the regular use of occlusal guards. iii. Substance abuse Drug and alcohol abuse should be considered a contraindication for implant therapy for reasons similar to the psychologic problems discussed earlier. Patient with such problem may be irresponsible and noncompliant with treatment recommendations. Depending on the severity and duration of an individuals addiction, some patients may be malnourished or may even have impaired organ
ii.

function and therefore may not be a good surgical candidate because of poor healing capacity. All elective treatments, including implant therapy, should be refused until addictions are treated and controlled.

4.

Oral status:
Evaluation may reveal the need for soft tissue. It is performed to assess the current health and condition of existing teeth.Patients can be categorized into: a) Edentulous patients b) Partially edentulous patients a. Edentulous patients: Patients who seem to benefit most from dental implants are those with fully edentulous arches.

Can be effectively restored, both esthetically and functionally, with an implanted-assisted removable prosthesis or an implant-supported fixed prosthesis. The original design for the edentulous arch was a fixed-bone-anchored bridge that used five to six implants in the anterior area of the mandible or the maxilla to support a fixed, hybrid prosthesis.

Another implant-supported design used to restore an edentulous arch is the ceramic-metal fixed bridge. Some patients prefer this design

because the ceramic restoration emerges directly from the gingival tissues in a manned similar to the appearance of natural teeth.

Limitationof the above two is that they provide very little lip support and thus may not be indicated for patients who have lost significant alveolar dimension. For patients not be able to be rehabilitated with an implant-supported fixed prosthesis, a removable, complete denture type of prosthesis is a better choice because it provides a flange extension that can be adjusted and contoured to support the lip, and there are no spaces for unwanted air escape during speech.

1) Partially edentulous patients Multiple teeth Endosseous dental implants can support a freestanding fixed partial denture.

 Adjacent natural teeth are not necessary for support, but their close proximity requires special attention and planning. Major advantage of implant-supported restorations in partially edentulous patient is that they are not invasive to adjacent teeth. Single tooth Also benefits greatly from the success and predictability of endosseous dental implants.

Replacement of a single missing tooth with an implant-supported crown is a much more conservative approach than preparing two adjacent teeth for the fabrication of a tooth-supported fixed partial denture. Esthetics consideration The prominence and occlusal relationship of existing teeth, the thickness and health of periodontal tissues, and the patients own psychological perception of esthetics all play a role in the esthetic challenge of the case. Cases with good bone volume, bone height, and tissue thickness can be predictable in terms of achieving satisfactory esthetic results.

 Intraoral examination: Make sure to evaluate the condition of the oral hard and soft tissue. Additional criteria to consider include the patient habit, level of oral hygiene, overall dental and periodontal health, occlusion, jaw relationship, temporomandibular joint condition and ability to open wide. Clinically measure the available space in the bone for the placement of implants and in the dental space for prosthetic tooth replacement. Precisely measurement of edentulous area can be done by measuring study models and radiograph imaging. a) Hard tissue evaluation The amount of available bone is the next criterion to evaluate. Important to analyze the anatomy of the dento-alveolar region of interest both clinically and radiographically. Clinical examination of the jawbone consistsof palpation to feel for anatomy defects and variation in the jaw anatomy. Measuring Mucosa thickness Hyperplastic tissue or scar formation sometimes make the clinical look much better than the actual skeletal picture.This is especially true with single tooth implant in maxilla because of the often very thick palatal soft tissues.The actual thickness of the mucosa can be measured under local anesthesia using sterile needle. The measured values can be transferred onto a cut section of a plaster model to give a realistic view of the alveolar process and its overlying mucosa.

A standard injection syringe needle with a rubber stop can be used as shown to measure the thickness of the soft tissue overlying alveolar bone which often obviate the necessity for expensive procedures such as tomography or CT.

Sectioned plaster model

The model is cut directly through the area where the implant is planned. The measurements takenclinically are transferredto the cut section to reveal both mucosa thickness and alveolar ridge profile. This helps to visualize the 3-dimensional contour of the alveolar process.

Transfer of mucosa thickness measurement

Mucosa thickness measurement also provide a good approximation of the cross sectional profile of the alveolar ridge on the model. Even though this is not an absolutely presice picture of the osseous situation, it is nevertheless quite helpful when making presurgical decision e.g. choice of the appropriate implant length and diameter.

Bone augmentation procedure may be necessary to facilitate the placement of an implant in an acceptable prosthetic position despite the availability of an adequate quantity of bone.

a) Soft tissue evaluation Assess of the quantity, quality and location of soft tissue present in the anticipated implant site helps to anticipate the type of tissue that will surround the implant. Smile line

Smile line analysis considering the face, smile line, tooth proportion, position and symmetry. In patient who exhibits a high smile line, Implant in the anterior area can only be used when osseous and soft tissue relationship are optimum.

B. Model Analysis
Diagnostic Study Models

An excellent means of assessing potential sites for dental implant. Study models are used to evaluate the possible width ( intercoronal distance ) and length of the planned implant-born crown in comparison to the other intraoral factors. Consideration must be given to the harmony of the entire anterior tooth group especially the position and shape of the contralateral tooth. Functional and occlusal aspect can also be evaluated using mounted study models . If an anterior overbite of greater than 4-5 mm exist, the danger of unfavorable functional loading of a single- tooth implant cannot be excluded. Insuch cases, the study models must reveal whether the implantborne single tooth crown will be protected by the neighboring teeth. i.e.that it will not play a direct role in mandibular guidance function. Allow clinician to evaluate the available space To determine potential limitation of the planned treatment. Useful when multiple teeth are to be replaced with implants or when malocclusion is present.

C.Ridge Evaluation For Spacing

Assessment of inter-arch spacing is critical in order to make sure there is adequate space for implant. The inter-arch distance is the distance between the arches in a vertical direction.

It may be over closed due to supraeruption of the dentition into an edentulous space or posterior deplacement of the condyle or wear of dentition as a result of loss of alveolar bone. This condition results in prosthetic challenge when there is significant loss of alveolar bone, onlay grafts followed by soft tissue reconstruction may be considered. Patient who have been edentulous for a long time or have suffered from severe periodontal bone loss typically have inadequate inter-arch space because they have had significant ridge resorption. In patient who have recently became edentulous, a thorough evaluation of inter-arch space is critical. This can be done with the aid of a diagnostic artificial tooth arrangement. The diagnostic arrangement is then indexed .The denture bases are then removed and the index is replaced onto the cast, and tooth position is re-evaluated relative to the location of the residual ridge. The same artificial tooth arrangement information in conjunction with the radiographic assessment will help determine the most suitable positions for implants.

D.Radiograph examination

Allow assessment of the quantity, quality and location of available alveolar bone in potential implant sites. Radiograph can help identify vital structures such as the floor of nasal cavity, maxillary sinus, mandibular canal and mental foramen. The best way to evaluate relationship of available bone to the dentition is using radiopaque marker that accurately represent the proposed prosthesis contours.

Periapical radiography

Periapical radiographs are produced by placing the film intraorally, parallel to the body of the alveolus, with the collimated parallel beam of the X-ray perpendicular to the alveolus at the region of interest, thus producing a lateral view of the alveolus. These are well suited for documentation and assessment of possibleperi-implant bone resorption during follow-up and are considered superior to panoramic radiography in this respect. With proper positioning techniques, periapicalradiographs give minimum magnification and distortion and the reproducibility of these radiographs is high. Nevertheless, the size of the film is often inadequate for the depiction of all the anatomic borders of interest for preimplant examinations. An edentulous alveolar ridge may not have the same long axis as a tooth; the image of the alveolar bone in the region of interest may be distorted, either foreshortened or elongated. It provides only a lateral view of the selected potential implant site without cross-sectional information, and the projections are not always perfect due to problems with film placement in resorbed jaws. This can cause inaccurate measurements in intraoral radiographs.

Panoramic radiography

It provides an approximation of bone height and vital structures and any pathological conditions that may be present. A panoramic image cannot provide clinicians with information about the buccolingual cross-sectional dimension or the inclination of the alveolar ridge. Angular measurements taken from panoramic radiographs tend to be accurate, but this is not true for linear measurements .Assessments of mesiodistaldistance can

be very imprecise due to inappropriate patient positioning and/or individual variations in jaw curvature. Although panoramic radiographs may provide a useful overview and may be used in conjunction with ridge mapping or other diagnostic tools, they are unlikely to meet the strict criteria set for primary imaging tests for implant planning.

Cephalometric radiography

Lateral cephalometric radiographs have been recommended for evaluating the anterior maxilla and mandible for dental implant placement .They can accuratelymeasure the height and width of the residual bone at the anterior midline of both the maxilla and mandible. Lateral cephalometric radiography also allows analysis of the quality of the bony host site (ratio of compact to cancellous bone), particularly that in the anterior region of the mandible . Lateral cephalometric radiographs offer limited information about the symphyseal area, and the inclination and buccolingual dimensions of the anterior jawbone region. They are not very useful when planning placement of implants lateral to the mid-sagittal plane. Moreover, due to the presence of genial tubercles, lateral cephalometricradiographs may create overly optimistic bone volume assessments.

Linear tomography

Cross-sectional tomography has been successfully applied in dental implant radiography. Cross-sectional tomographs have been shown to be more precise than panoramic radiographs when measuring the distance between the alveolar crest and the mandibular canal . The disadvantage of using conventional linear tomograms is the lack of adequate cross-referencing with standard lateral, frontal, and panoramic radiographs.

Computed tomography
Computed tomographic scanning, which allows exact preoperative analysis of the available bone volume and helps to determine the appropriate position, angulation, number, and length of the planned implants, is highly recommended. Computed tomography provides a much more accurate estimate of the position of the mandibular canal than does periapical and panoramic radiography and hypocycloidal tomography.

Magnetic resonance imaging

It has recently been proposed that MRI be used as an alternative technology for implant planning to avoid the radiation hazards associated with the use of CT. MRI does not yield cortical bone images, so estimation of bone quality may be problematic.

E.BONE QUALITY CLASSIFICATION

Bone can be classified according to structure, composition, density and volume. Bone quality is classified in to four groups D1, D2, D3, and D4 whereby the Misch classification suggests a location, composition and a measurable density reading (Hounsfield units) for each type of bone. The interplay of bone quality and volume has a direct influence on the success rate and drill protocol for Endosseous (Endosteal) implants as well as the esthetics and function of the final prosthesis. D1 type bone

D1 bone is composed of almost all cortical bone mass located primarily in the anterior mandible. A Hounsfield unit reading of 1250 and above indicates D1 bone. This type of bone results in the greatest bone to implant contact (BIC) and exceptional initial implant stability. Due to its density this type of bone has fewer intrinsic blood vessels and depends for a significant portion of nutrient and blood supply on the periosteum. Conservative flap reflection is advised to lessen the impact of the disrupted blood supply during and after surgery. To minimize detrimental heat generation during the osteotomy it is advantageous to use copious amounts of pre cooled sterile saline solution for cooling. Smaller increments in drill diameter combined with drill speeds around 2000 rpm and a force of around 2 kg will ensure efficient bone cutting while heat generation is kept at acceptable levels. Each implant manufacturer recomends specific drill speed ranges for task specific drills. Using a slow pumping motion will further decrease heat generation. D2 type bone

D2 bone is composed of a thick crestal layer of cortical bone and coarse trabecular bone underneath the cortical bone. This type of bone can mostly be found in the anterior and posterior mandible. A Hounsfied reading between 850 to 1250 units is indicative of D2 bone. This type of bone offers a excellent BIC ratio and presents with abundant intrinsic vascularization due to its coarse structure. The drill protocol is slightly less demanding in terms of drill diameter sequence, fewer drills may be necessary to achieve final osteotomy dimensions. Drill speed, exerted force, pumping motion and pre cooled, sterile saline solution irrigation are the same as D1 bone. D3 type bone

D3 bone is composed of a porous crestal layer of cortical bone and fine trabecular bone underneath the cortical bone. This type of bone can mostly be found in the anterior and posterior maxilla but also in the posterior mandible. A Hounsfield reading between 350 and 850 units is indicative of type D3 bone. Due to the porous architecture of D3 bone the BIC is significantly reduced and warrants a modified drill protocol and procedure. A reduced number of drills and a osteotome may be indicated to achieve final osteotomy dimensions in combination with a reduced drill speed (1500 rpm) and force. Each implant manufacturer recomends specific drill speed ranges for task specific drills. Great care should be taken not to create a oval osteotomy or perforate the buccal plate in the anterior maxilla. The anterior maxilla presents with a challenging environment because the palatal aspect of the anterior maxilla is often denser and thicker than the labial portion, forcing the drill during the osteotomy and the implant during insertion more labially resulting in a possible elliptical osteotomy and a perforated labial plate. To further enhance osseointegration and counteract the limited bone density it may be favorable to utilize implants with a titanium plasma spray (TPS) or hydroxylapatite (HA) coating. The coarse structure of D3 bone is well vascularised and therefore aides in osseointegration. D4 type bone

D4 bone is composed of primarily fine trabecular bone and often the absence of cortical bone. This type of bone can mostly be found in the posterior maxilla and poses the greatest challenge in implant placement. A Hounsfield reading between 150 and 350 units is indicative of D4 bone. Due to the fine trabecular architecture and often absence of a cortical bone structure D4 bone results in the least amount of BIC. As with D3 bone a modified surgical procedure and drill protocol are necessary. A undersized osteotomy and the use of osteotomes to condense rather than remove bone will enhance the predictability and success rate in combination with TPS and HA coated implants.

2.CONTROL OF ACTIVE DISEASES

Active periodontal infection must be treated and controlled before the initiation of restorative, esthetic, and implant dentistry to achieve the long term therapeutic predictability, longevity and ease of restorative and maintenance care. The rationales to control active diseases are: 1. To ensure the establishment of stable gingival margins before tooth preparation. 2. Resolution of inflammation may result in the repositioning of teeth or in soft tissue and mucosal changes. 3. Traumatic forces placed on teeth with ongoing periodontitis may increase tooth mobility, discomfort and possible the rate of attachment loss. 4. Successful esthetic and implant procedures may be difficult or impossible without the specialized periodontal procedures developed for this purpose. Procedures are as followed: 1. Emergency treatment: Undertaken to alleviate symptoms and stabilize acute infection Includes endodontic and periodontal conditions 1. Extraction of hopeless teeth: Retention of hopeless teeth without periodontal treatment may result in bone loss on adjacent teeth 1. Oral Hygiene Measures: Shown to reduce plaque scores and gingival inflammation, however difficult for patients with deep periondontal pocket (>5 mm)

1. Scaling and root planning: Significantly reduce gingival inflammation and the rate of progression of periodontitis if combined with oral hygiene measures

1. Reevaluation: After 4 weeks, gingival tissues are evaluated to determine oral hygiene adequacy, soft tissue response and pocket depth. Permits sufficient time for healing, reduction in inflammation and pocket depths, and gain in clinical attachment levels. Periodontal surgery for pocket depth more than 5mm to access the rooth surfaces for instrumentation and to reduce periodontal pocket depths 1. Periodontal Surgery: Should be undertaken with future restorative and implant dentistry Some are intended to treat active disease successfully, and some are aimed at the preparation of the mouth for restorative or prosthetic care.

3.Pre-Implant Surgeries 1) Frenectomy:

Labial frenum consists of thin bands of fibrous tissues covered with mucosa extending to the lip and check to the alveolar periosteum. Its attachment varies from the height of the vestibule to the crest of the alveolar ridge and may extend to the incisal papilla area in the anterior maxilla. In the presence of the dentition, the frenalattachement do not problems, but denture construction may be complicated by its high attachment as it may create areas of discomfort and ulceration and interfere with the peripheral seal dislodging the denture. Techniques:

1) Simple excision
L.A. usually is effective, but do not inject excessive anesthetic solution to avoid disturbance of the anatomy that should be visualize at the time of excision

The lip should be everted. An elliptical incision around the frenum to the periosteum is completed.Woundunderminded and re-approximated (first suture should be placed at the height of the vestibule beneath the anterior nasal spine, and if it is difficult to close the portion close to the alveolar crest, it will undergo secondary

epithelialsation without difficulty.

1) Z-Plasty technique

-after excision as in the simple technique, two oblique incision in Z-fashion, one on each endof the previous area of excision.

The two pointed flap are underminded and rotated to close the initial vertical incision horizontally

1) Localized vestibuloplasty technique with secondary epitheliasation

L.A. given

Supraperiosteal incision Undermind the mucosal and submucosal tissue with scissors The edge of the flap is sutured to the periosteum at the maximal depth of the vestibule.

Surgical splint with soft liner to help healing is useful.

1. Lingual frenectomy:

It consists of mucosa, dense fibrous connective tissues, fibers of genioglossus muscle and it extends from thetip of the tongue to the posterior surface of mandibular alveolar ridge. It may affect speech and denture stability Technique of removal:

 Bilateral lingual nerve block. Tongue traction by heavy suture to control its movement.

Two hemostats are placed across the frenal attachment meeting each other at the base of the tongueand an incision is made over the hemostates (above and below), and careful attention is given to theblood vessels at the inferior aspect of the tongue and floor of the mouth and to the submandibular duct opening .

Suture the wound by closing the base of the tongue only and do not close the floor of the mouth to avoid stricture of the submandibular salivary gland duct.

1)Sinus floor augmentation

1. Maxillary Sinus Augmentation / Lift The maxillary sinuses are on top of the upper molars. Some of the roots of the upper molars extend up into the maxillary sinuses. When these upper teeth are removed, there is often just an egg shell thin wall of bone separating the maxillary sinus and the mouth. Dental implants need bone to hold them in place so when the sinus wall is very thin, it is impossible to place dental implants in this bone. Sinus graft or sinus lift graft can solve this problem. Types of sinus lifting procedure I. Direct technique a) Lateral window approach b) Caldwell-Luc technique I. Indirect technique Procedure of Lateral Window Approach

After incision, soft tissue in anterior maxilla has been reflected back to expose overlying maxillary sinus (arrowheads). Osteotomy done on the thin bone area covering maxillary sinus. (arrows)

cross-sectional (lateral) view of maxillary sinus. Bone flap created by osteotomy has been pushed inward with maxillary sinus membrane, creating space for packing of bone graft material.

(cross-sectional view ) Start packing the space with bone graft. Bone graft fills space created by inward displacement of osteotomy and sinus membrane. After average 12 months of healing, the bone becomes part of the patient's jaw and dental implants can be inserted and stabilized in this new sinus bone. Pre/Post Operative Instructions:
1) Peridex: Rinse with 15mL (1/2 oz.) for 30 seconds every 12 hours (twice

a day), until the sutures have been removed. (Start 1 day before sinus graft) 2) Ibuprophen: Take one (600mg) tablet every 6-8 hours 3) A twelve hour antihistamine and decongestant tablet. Take one tablet one hour prior to surgery and continue to take one tablet every 12 hours (total of two tablets per day) for 10 days. 4) Antibiotics:

5)

6)

7) 8) 9)

There may be occasional bleeding for the first couple of days. Nose bleeding may occur after the procedure.(To avoid bleeding, do not blow your nose for the first week) Swelling is to be expected. To help keep the swelling down place ice on the outside of the face (5 min. on & 5 min. off) for 24-48 hours after the procedure. In After 2 days, place a warm compress on the outside of the face (5min. on & 5min. off), until the swelling decreases. If there are teeth present in other areas of mouth clean them with toothbrush as you usually do; however, avoid contact with the surgical wound. Removable denture appliances they should not be worn Avoid seeded and hard foods until after the sutures have been removed. Consumption of alcoholic beverages & smoking is not allowed for two weeks.

Risks:
1) The bone substitute material does not turn into bone.The bone substitute material grows into the connective tissue. 2) A rupture of the mucous membrane of the maxillary sinus leading to the loss of the bone substitute material. 3) An inflammation of the augmentation. This inflammation may spread to neighboring structures (maxillary sinus, eyes, etc.). Removal of the augmentation material in a second surgical procedure is often necessary 4) Injury to neighboring structures such as nerves, cheeks, and blood vessels, with the respective consequences 5) Maxillary sinusitis 6) Sensation disturbances in the lip and upper jaw

Procedure of Caldwell-Luc technique

A sublabial incision made in the buccal sulcus from the left lateral incisor to the ipsilateral first molar tooth. The mucoperiosteal flap or anterior maxillary periostium was raised and elevated to a point at which the left inferior orbital nerve can be identified and protected. An anterior window or antrostomy was made into the sinus through the thin bone of the whole canine fossa by a bur. The sinus lining was incised and blood was then carefully removed using a sucker. The area in which the root was identified from the radiograph taken before surgery, was located. Irrigation of the sinus with normal saline, the sinus lining was left intact and incision was closed suture.

A buccal advancement flap was then used to close the oroantral fistula at the extraction site. Give treatment consisting of a course of broadspectrumantibiotics, (Sultamicillin) and analgesics, (Paracetamol). Nasal drops (Ephedrine) and inhalations (Menthol) were used for 5 days. The patient was instructed not to blow his nose during the postoperative period.

Indirect Sinus Lift

Is also called an osteotome sinus lift. This type of sinus lift is performed when there is enough bone to place a stable implant but 1-3mm of lifting is needed in order to prevent puncturing the sinus membrane. A hole is drilled and implant site prepared in the area where the implant is to be placed without going into the sinus membrane. Before inserting the implant, bone is placed into the hole and an instrument used to place gentle pressure on the bone which acts like a hydraulic jack to lift the bone, which in turn lifts the membrane. This is repeated several times with the implant itself used as the final instrument to lift the bone and membrane when placed. Sinus lifts (augmentation) have been shown to greatly increase chances for successful implants that can last for years to come.

The fill material used for the sinus lift can be autologous bone, but in some cases sufficient to donorbot for filling out the mouth without a place to use (eg hip) is also mixed with autologous bone eg artificial bone. Some indications are also artificial bone used alone, or in combination with growth factors extracted from blood. Depending on the amount available under the jaw bone cavity simultaneously with the sinus lift an implant placed.

1)Socket preservation
Alveolar Ridge Preservation is the term used for measures preserving the alveolar crest, particularly for dental implant therapy. This circumstance makes implantation possible only by employing difficult and expensive measures for building up the bony structures, such as autologous transplants from the iliac crest, hip or mandible. This can be avoided if the alveolus is augmented with bone graft material immediately after the tooth is extracted. If required, a membrane for "Alveolar Ridge Preservation" (Salama 1993) can be used to facilitate and improve the bony healing of the deficiency. It is well known that the alveolar bone collapses after extraction. Bone healing, i.e., healing of the socket, in many aspects is similar to healing by secondary intention. The alveolar bone loss in height and width within the first 6 months is 3-4mm and, thus, the bone is insufficient for a subsequent implantation procedure and to achieve excellent aesthetic results of the final prosthetics (Sclar 1999). Without bone preservation measures, the resorption of alveolar bone is 40-60% within the first 2-3 years. The extraction sockets are filled with a bone graft material and covered with a membrane to enable a bony healing of the deficiency without the risk of soft tissue migration into the socket. For this research data was collected by a study group of experienced implantologists in their private practices.

Keys to successful extraction-socket grafting: The surgeon who removes the toothmust evaluate the area for immediate orfuture dental implants. To that end, theperson who will install the implant or graftsshould perform the extraction.According to Dr. Carl Misch, founder ofthe Misch International Implant Instituteand one of the worlds leading implantologists,some keys to successful bone grafting of extraction sites include: 1. Atraumatic tooth removal; 2. An evaluation of the remaining walls ofbone following the extraction, and evaluation of the size of the defect; 3. Asepsis and complete removal of granulomatoustissue 4. Ensuring adequate blood supply to thegraft site; 5. Graft containment and soft tissue closure; 6. Choice of an appropriate graft material; 7. Ensuring adequate time for healing.

Steps in Socket Preservation:

1) Asepsis and Removal of granulomatous tissue: Before an extraction site can receive agraft, any granulomatous tissue present must be removed. This can be accomplishedwith a Molt curette or other similar surgical instrument. In order for theosteoprogenitor cells to reach the graft siteand allow for bone formation and remodeling,infection must also be prevented.

Periotomes, requiring less force than forceps, help achieveatraumatic extraction by gently pushing bone away from the tooth root. 2) Ensuring adequate blood supply to the graft site: A bone graft requires a blood supply toprovide osteoprogenitor cells and associatedgrowth factors. Without an adequateblood supply, the graft will not be successful.While soft tissue does supply bloodto the graft site, osteoprogenitor cells aresupplied only from adjacent bone, or in alimited fashion from the periodontal ligament. To ensure the presence of these criticalcells, the bone adjacent to a graft sitemust be traumatized in a non pathologicalfashion. This has been called aRegional Acceleratory Phenomenon(RAP).

Site of extraction socket 3) Graft containment and soft tissue closure: When the extraction site is an optimal5 wall defect, the surrounding walls of bonewill contain and immobilize the graft. Graftingbone into a 5 wall defect usuallyrequires only coverage of the graft site witha rapidly resorbing collagen membrane stabilized with sutures. If the extraction sitehas 4 walls or less, the surgeon uses a barriermembrane to contain the graft materialand exclude fibrous cell ingrowth. Eachextraction site grafting situation is unique,and must be based on the treatment plan.

Grafting bone into a 5 wall defect usually requires coverage of the graft site with a rapidly resorbing collagen membrane (such as the Colla Plug Collagen membrane) and stabilizing with sutures. 4) Choice of appropriate graft material: The choice of graft material is based onmany factors. The most important determining factor is the number of remainingwalls of bone. As a general rule, the importance of using autogenous bone increasesrelative to the number of bony walls that are missing. Another factor that determinesgraft material selection is the prosthetic treatment plan. Each type of available graftmaterial offers different characteristics andadvantages.

Iso-dent Cyanoacrylate adhesiveused to hold &adhere thesuture to the Colla-Plug membrane 5) Ensuring adequate time for healing: To allow a graft to mature into lamellar bone, adequate time for healing is needed. The time required is dependent on factors such as the patients age, healing capacity, residual infection in the graft site and size of the defect. In general, the time for a graft to heal varies between 3 and 6 months depending on the graft material used.

Bone grafting material: The importance of using autogenous bone increases relative to the number of bony walls that are missing

1)Ridge augmentation and ridge reconstruction

HORIZONTAL RIDGE AUGMENTATION:
Indication:
1. Block bone grafts harvested from the symphysis can be used for predictable bone

augmentation up to 6 mm in horizontal and vertical dimensions Principles for predictable block bone grafting Recipient site: soft and hard tissue considerations Incision design at the recipient site for block grafting varies depending on location within the arches. Maxillary anterior sites require a midcrestal incision that continues in the sulcus for a full tooth on either side of the defect. Bilateral oblique release incisions are made approximately one tooth removed, and a full-thickness mucoperiosteal flap is reflected (Fig. 3).

Fig. 1. Symphysis and ramus buccal shelf block grafts harvested from same mandible. Note relative greater cortical thickness of the symphysis grafts.

Fig. 2. Fixation of symphysis and ramus block grafts. The two anterior vertical blocks are from the symphysis; the posterior block is from the ramus buccal shelf. Note donor sites.

Box 1. Symphysis block graft: indications Horizontal augmentation 47 mm (up to three-tooth defect) Vertical augmentation 46 mm (up to three-tooth defect)

Method:
1. Through the use of intraoral autogenous block grafts. 2. The blocks are harvested from the patients symphysis or ramus. The donor sites

3.

4.

5. 6.

are surgically isolated, and the appropriately sized blocks are cut with rotary instruments, reciprocating saws, or piezo electric saws and removed. The perforation of cortical bone has been proven to enhance bone regeneration.5 The donor sites are then treated with bone replacement grafts and/or haemostatic agents, as advocated by Misch,6 and closed. The dense cortical bone at the recipient site is decorticated to facilitate vascularity in growth and migration of cells into the desired regenerated site. The block is then closely adapted to the recipient site with fixation screws. Tension-free closure of the overlying flap is achieved, and time to allow for incorporation of the block precedes fixation screw removal and implant placement. This technique is widely used and investigators report varying levels of success.

Disadvantages:
1. Resorption of the block, resulting in suboptimal bone regeneration. Cordaro7 et al

reported approximately 25% horizontal graft reduction using this technique. Methods to reduce the resorption of autogenous block grafts have been tested, often with positive results.
2. time necessary for mesh shaping, manipulation, and fixation. 3. greatest shortcoming of titanium mesh is the necessity of its removal. This requires wide flap reflection and frequently sharp dissection. Often, a dense, soft-tissue layer is found over the mesh, referred to by Boyne10 as a pseudo-periosteum. This tenacious soft tissue is tightly bound to the mesh and underlying bone, requiring sharp dissection and elevation of the material.

VERTICAL RIDGE AUGMENTATION

Vertical augmentation of severe localized edentulous atrophic alveolar ridges is still challenging. The membrane technique (guided bone regeneration) has been shown to be a valuable and predictable treatment method. In vertical ridge augmentation greater membrane stability is currentlyCrequired Vertical bone regeneration in a (partially) edentulous jaw in order to provide sufficient long-term stability for implant-supported tooth restorations

Bone Augmentation With Barrier Membrane Technique The concept of GBR was described first in 1959 when cell-occlusive membranes were employed for spinal fusions. It is the concept that the uses barrier membranes for space maintenance over a defect, promoting the ingrowth of osteogenic cells and preventing migration of undesired cells from the overlying soft tissues into the wound The technique can be applied to extraction socket defects, horizontal and vertical ridge augmentation, and the correction of dehiscence and fenestration defects around implants. Successful vertical ridge augmentation with the GBR technique, using titanium reinforced expanded polytetrafluoroethylene (ePTFE) membranes, was shown in human and animal studies. The use of titanium mesh as a barrier maximizes graft containment and eliminates the space maintenance collapse problems that are associated with conventional membranes. The pattern of bone regeneration involves angiogenesis and ingress of osteogenic cells from the defect periphery toward the center to create a well-vascularized granulation tissue. This provides a scaffold for woven bone proliferation and bone apposition within the defect. The size of the defect influences the bone healing capacity. In circumstances where the defect is too large to generate a biomechanically stable central scaffold, bone formation is limited to the marginal stable zone with a central zone of disorganized loose connective tissue. Thus, combined use of bone grafts or bone replacement substitutes with barrier membranes are advocated in bone regeneration of larger defects. Repair of osseous defects closely resembles appositional bone growth during which the woven bone construction acts as a template for lamellar bone formation. As in the healing

pattern observed in extraction sockets, organization of the blood clot is followed by ingrowth of vascular tissue and deposition of woven bone. Reinforcement of this disorganized bone structure is accomplished by lamellar bone formation, which, in turn, is remodeled soon after as is evident by the presence of secondary osteons.

Maintenance of primary wound closure throughout the healing period is critical to the outcome of GBR. Despite the success demonstrated with ePTFE membranes in GBR application, complications of soft tissue dehiscence with membrane exposure and infection impaired the outcome of therapy with a decreased gain in bone fill. To overcome some of the limitations of non-resorbable membranes, such as the need for a second surgical procedure for their removal with the added risk of loss of some of the regenerated bone further to flap reflection, they largely have been replaced with bioabsorbable membranes.

Like the non-resorbable membranes, bioabsorbablemembranes can experience premature soft tissue dehiscences and exposures. However, communication with the oral cavity accelerates their resorption rate, and, thus, reduces prolonged contamination of the regenerated bone matrix. Although collagen barriers offered improved soft tissue response, they lacked the ability to maintain adequate defect space. Choice of membrane depends largely on the required duration of membrane function for tissue regeneration (~6 months). The volume of regenerated bone generally is more encouraging with non-resorbable ePTFE membranes than with bioabsorbable membranes.

Figure 1. A) Preoperative view of defect, 2 months postextraction, demonstrating both vertical and horizontal deficiencies. B) Adaptation of a titanium-reinforced membrane secured with stabilization pins. C) Reconstructed ridge deficiency allowing ideal tri-dimensional implant placements (D).

1)Nerve reposition surgery

a) Indication: Indicated when teeth are missing in the area of the two back molars and/or and second premolar, with the above-mentioned secondary condition. b) Limitations: Limited only for lower jaw c) Procedures: Typically we remove an outer section of the cheek side of the lower jawbone in order to expose the nerve and vessel canal. Then we isolate the nerve and vessel bundle in that area, and slightly pull it out to the side. At the same time we place the implants, well be tracking the neuro-vascular bundle. Then the bundle is released and placed back over the implants. The surgical access is refilled with bone graft material of the surgeons choice and the area is closed.

These procedures may be performed separately or together depending upon the individual's condition. As stated earlier, there are several areas of the body that are suitable for attaining bone grafts. In the maxillofacial region, bone grafts can be taken from inside the mouth, in the area of the chin or third molar region or in the upper jaw behind the last tooth. In more extensive situations, a greater quantity of bone can be attained from the hip or the outer aspect of the tibia at the knee. When we use the patients own bone for repairs or addition, we generally get the best results. In many cases, we can use allograft material to implement bone grafting for dental implants. This bone is prepared from cadavers and used to get the patients own bone to grow into the repair site. It is quite effective and very safe. Synthetic materials can also be used to stimulate bone formation. We

even use factors from your own blood to accelerate and promote bone formation in graft areas. These surgeries are performed in the out-office surgical suite under IV sedation or general anesthesia. After discharge, bed rest is recommended for one day and limited physical activity for one week. d) Complications: Since this procedure is considered a very aggressive approach (there is almost always some postoperative numbness of the lower lip and jaw area, which dissipates only very slowly, if ever). Usually other, less aggressive options are considered first (placement of blade implants, etc.)

SUMMARY:
Dental clinicians can now predictably replace missing teeth with endosseous dental implants. Most patients, whether missing a single tooth, several teeth or all their teeth can be candidates for dental implant therapy. However, many factors influence the outcome; the clinician must consider the quantity, quality, and location of available bone; the patients mental and physical health; and risk factors and contraindications. Patient should be advised about the risk factors and provided treatment options both with and without dental implants. Periodic evaluation, good oral hygiene and regular maintenance are important aspects of care for the long term success and the prevention of complications with dental implants. Radiographic examination and mobility tests appear to be some of the most reliable parameters in the assessment of endoosseous dental implants.

REFERENCES:
1. Periodontology Carranza 2.http://www.joponline.org/doi/abs/10.1902/jop.1974.45.8.601 3. http://www.dent.ucla.edu/pic/visitors/pfs/pfs.03.html 4. http://www.thonglordentalhospital.com/Nerve_Repositioning.aspx 5. http://www.surgeryencyclopedia.com/Fi-La/Gingivectomy.html 6. http://www.gumrecession.com/thinfragile.html 7. http://en.wikipedia.org/wiki/Guided_bone_and_tissue_regeneration