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General notions.

Indications and
contraindications in oral implantology
Associate professor, doctor of medicine, maxillofacial
surgeon, implantolog.
Head of department propedeutic dentistry and
dental implantology

Nicolae Chele
CHIŞINĂU
MOLDOVA
Dental implantology is a part of
plastic / esthetic oral surgery, because
due to implant insertion is created an
oclusal rehabilitation with different
prosthetic constructions, these
reestablish more phisiologically the
chewing, phonetics, the oral confort and
the esthetics.
The
development
history of
dental
implantology
 Itsupposes that the first implants
and dental transplantations were
used in Egipt.
In 1931, on Las Mouertos plateau,
Republic of Honduras, doctor D.
Popenoe has found an fragment of
mandible from 6th century a.Ch. In 31,
41, 42 teeth socket were found dental
implants made from mussels shells.
In 1998, a goup of researchers have found
a 30 year old woman’s skull (France), that
lived in the first century, having a metallic
dental implant in the socket of a superior
canine
Another
revolution in the
history of dental
implantology was the
discovery and the
usage of Titanium as
a biomaterial
The titanium as a
biomaterial in
implantology
Brånemark's discovery of
osseointegration revolutionized the realm of
implant dentistry and brought it from being a
shunned field into one that became
recognized and incorporated into] dental
school curricula and training programs.
Prior to the discovery of osseointegration,
dental implant technology consisted of blade
and transosteal implants
Blade implants, introduced in 1967, consisted of a metal blade that was
placed within a bony incision that subsequently healed over the horizontally
situated piece of metal but allowed a vertical segment to perforate the healed
surface. Transosteal implants, the application of which was strictly limited to the
mandible, consisted of a number of screws which were inserted into the inferior
aspect of the mandible, some of which extended through and through into the oral
cavity.
Both of these implant types relied on mechanical retention, as it was
heretofor unknown that metal could be fused into the bone. With the advent of
osseointegration, however, rootform endosteal implants became the new standard
9
in implant technology.
Brånemark's serendipitous discovery of osseointegration occurred
in 1952 during vital microscopy studies in rabbits using titanium
optic chambers. He and his team found that titanium oculars placed
into the lower leg bones of rabbits could not be removed from the
bones after a period of healing. He then developed and tested a type
of dental implant utilizing pure titanium screws, which he termed
fixtures.
Although the field of implantology was eschewed by dental
academia until that time, the "extensive and weighty documentation
of implant efficacy and safety" and "early replication by reliable,
independent researchers" resulted in the widespread embrace of
implantology by the dental community.
Brånemark's son, Rickard, has taken this success and is
developing orthopedic prostheses in the form of artificial arms and
legs anchored to the human skeleton.
The romanian researcher, Dorin Bratu, divides the evolution
of dental implantology in 5 stages:
The medieval period – 1001-1799
The fundamental period – starts in XIXth century when has
appeared the Maggiolo dissertation, named “The dental art
handbook”
The premodern period – starts in 1913, when Greenfield
presented at the Philadelphia academy a study about an iridium-
platinum cylindrical implant
The modern period – starts at the end of 1938 year when it
begun the usage of stainless materials (chromium, cobalt,
molybdenum)
The contemporary period – dates till nowadays and it begun
once biomaterials and the osseointegration phenomena were
discovered by Branemark
The development of dental
implantology in Moldova
The first internship of implantology
was held in Caunas city, ex Lithuanian
Socialist Sovietic Reupublic, in 1986.

13
25 years is a lot of
time or not?
 The first plate form implant was introduced
in a new created socket on the maxilla in
1987 year, 23 July
In 1990, professor B. Heinrich came
and taught a course about the blade-
implant inoculation technique.
After finishing the lessons, some
specialists like A. Păulescu, T.Popovici,
Gh. Nicolau, I.Şeptelici a.a begun to
practice implantology.
After the unraveling USSR, the possibility of
developing dental implantology raised, and in 1995-
1997, another specialists like V.Topală, D. Şcerbatiuc, in
professor’s Burchel clinic from Germany, G. Nicolau
profesor’s Postata clinic from Czech Republic, N. Chele
in profesor’s Bayer clinic – Germany, started to make
internship in this field.
In 1998 were brought in our country the first single
step surgery implant (CTИ ол Rusia) and the last
generation of two step surgery implant (Alpha Bio) by
N. Chele.
At this moment work a large number of stomatologists
like C. Gligor, D,Sârbu. F. Gheorghiţa, I. Dabija, in this
domain.
DENTAL
IMPLANTS
TYPES AND CLASSIFICATION
INTRODUCTION

IMPLANT DENTISTRY is a boon for restoration of


missing teeth .
It overcomes many disadvantages of other
conventional methods of restorations
i.e.,
with removable prosthesis
with fixed prosthesis .
WHAT IS IMPLANTATION?

 IMPLANTATION – is defined as
insertion of any object or a
material , which is alloplastic in
nature either partially or
completely into the body for
therapeutic , experimental ,
diagnostic or prosthetic purpose .
- ANUSAVICE
ADVANTAGES OF IMPLANT

 to overcome the drawbacks of


removable prostheses
 Bone maintenance of height and width
 Ideally esthetic tooth positioning
 Improved psychological health
 Increased stability in chewing
 Increased retention
 Eliminates need to involve adjacent teeth
CLASSIFICATION
OF DENTAL
IMPLANTS
5 Types of
classification
1.Based on implant design
2.Based on attachment mechanism
3.Based on macroscopic body design
4.Based on the surface of the implant
5.Based on the type of the material
CLASSIFICATION
BASED ON IMPLANT
DESIGN
BLADE
FORM
1.ENDOSTEAL IMPLANT

 A device which is placed into the


alveolar bone and/or basal bone of
the mandible or maxilla
 Transect only one cortical plate
a) BLADE IMPLANT

 It consist of thin plates in the form of


blade embedded into the bone
b) RAMUS FRAME IMPLANT

 Horse shoe shaped stainless steel


device
 Inserted into the mandible from one
retromolar pad to the other
 It passes through the anterior
symphysis area
c) ROOT FORM IMPLANT
 Designed to mimic the shape of the tooth
 For directional load distribution
2. SUBPERIOSTEAL IMPLANT

 Placed directly beneath the


periosteum overlying the bony cortex
3. TRANSOSTEAL IMPLANT

 Other names- staple bone implant


mandibular staple implant
transmandibular implant
 combines the subperiosteal and
endosteal components
 Penetrates both cortical plates
3. TRANSOSTEAL IMPLANT
4.INTRAMUCOSAL IMPLANTS

 Inserted into the oral mucosa


 Mucosa is used as attachment site for
the metal inserts
CLASSIFICATION
BASED ON
ATTACHMENT
MECHANISM OF THE
IMPLANT
FIBROINTEGRATION

 Proposed by Dr.Charles Wiess


 Complete encapsulation of the
implant with soft tissues
 Soft tissue interface could resemble
the highly vascular periodontal fibers
of natural dentition
OSSEO-INTEGRATION
 Direct contact between the bone and the
surface of the loaded implant
 Described by BRANEMARK
 Bio active material that stimulates the
formation of bone can also be used
CLASSIFICATION
BASED ON
MACROSCOPIC
BODY DESIGN OF
THE IMPLANT
CYLINDRICAL DENTAL
IMPLANTS
 in the form of cylinder
 Depends on coating or surface
condition to provide microscopic
retention and bonding to the bone
 Pushed or tapped into a prepared
bone site
 Straight, tapered or conical
THREADED DENTAL
IMPLANTS
 The surface of the implant is
threaded, to increase the surface area
of the implant
 This results in distribution of forces
over a greater peri-implant bone
volume
PLATEAU- DENTAL
IMPLANTS
 Plateau shaped implant with sloping
shoulder
PERFORATED DENTAL
IMPLANTS
 The implants of inert micro porous
membrane material (mixture of
cellulose acetate ) in intimate contact
with and supported by the layer of
perforated metallic sheet material
(pure titanium)
SOLID DENTAL IMPLANTS

 They are of circular cross section


without vent or hollow in the body
VENTED DENTAL IMPLANTS

 It is hydroxyapatite coated cylinder


implant patented vertical groove
connecting to the apical vents were
designed to facilitate seating and
allow bone ingrowth to prevent
rotation
HOLLOW DENTAL IMPLANTS

 Hollow design in the apical portion


 Systematically arranged perforations
on the sides of the implant
 Increased anchoring surface
CLASSIFICATION
BASED ON THE
SURFACE OF THE
IMPLANT
SMOOTH SURFACE IMPLANT

 It has a very smooth surface


 To prevent microbial plaque
retention, smooth surface is essential
MACHINED SURFACE
IMPLANTS
 For the purpose of better anchorage of
implant to the bone, the surface of the
implant is machined
TEXTURED SURFACE
IMPLANT
 The implants of increasing surface
roughness of the area to which bone
can bond
COATED SURFACE IMPLANT

 The implant surface is covered with a


porous coating
 The materials used for coating are
-titanium
-hydroxyapatite
CLASSIFICATION
BASED ON THE
IMPLANT
MATERIAL
METALLIC
IMPLANT
 Most popular material in use today is
TITANIUM
 Other metallic implants are
- stainless steel
- cobalt chromium molybdenum alloy
- vitallium
CERAMIC & CERAMIC COATED
IMPLANTS
 These materials are also used to coat
metallic implants
 These ceramics can either be plasma
sprayed or coated to produce bio
active surface.
 Non reactive ceramic materials are
also present
POLYMERIC
IMPLANT
 In the form of
polymethylmethacrylate &
polytetrafluoroethylene
 Have only been used as adjuncts
stress distribution along with
implants rather than used as implants
by themselves
CARBON IMPLANTS

 Made up of carbon with stainless steel


 Modulus of elasticity equivalent to
bone and dentine
 Brittleness leads to fracture
Dental implant types:
Submucosal implants
Subperiosteal implants
Endoosseous implants
The endoosseous
implant (root form)
The endosteal implant
 Single step
surgical implant
 1 piece implant

 Two steps
surgical
implants
The component parts of two steps
surgical implants
The surgical parts

 The implant`s body

 The healing screw


The surgical parts

 The healing cap


The prosthetic parts:
- clinical
- laboratory
 Transfer copings
The clinic prosthetic
componentes are abutments:
 Standard

 Individual
Standard

 straight
 angulate
Straight Abutments :

 Short straight;

 Long straight;
Standard short straight
abutments
Standard angulated abutments :

Abutments:

 Angulated at 150
 Angulated at 250

 Angulated at 350
 Short angulated at 150;

 Long angulated at 150


The clinical
prosthetic components:
 The coping transfer
 for dental impression trays
The clinical
prosthetic components:
 The coping transfer
 for disposable dental

impression trays
The laboratory Components

The analog implant


The indications and
contraindications in oral
implantology
In the last decade, the reconstruction
technique on dental implants has been
considerable modified. If before the hole
atention was concentrated only on the tooth
or teeth that had to be replaced, nowadays
the practician must keep atention on
different interacting factors
before establishing
an treatment plan
Indications: locally, in
almoust all types of
endotulous jaws
Contraindications:

local
relative

general
absolute
The local relative
contraindications are:
Poor oral hygiene
the existance
of radicular
residues
Diseases of oral mucosa
Stomatitis,
bacterial
Infections,
ulcers, lupus
erythematosus,
pemphigus,
alergies
Local inflamatory
pocesses

parodontitis,
gingivitis,
stomatitis
Poor narrow bone

Bone defects,
narrow bone,
porous bone
Qualitatively thin bone
Large interdental spaces and dental migrations.
Pathological occlusion
General relative
contraindications
 Neoplasme or precancerous stages
Postradiotherapy status
 Endocrinopathies (acromegaly)
Granulomatous diseases (tuberculosis,
sarcoidosis)
Pregnancy
The absolute contraindications are:
 biphosfstasis therapy;
 echtodermal dysplasia;
 treatment by an surgeon-implantologist without any
practice;
 type II diabetes (decompensated stage);
 prolonged treatment with imunosupresor medicine;
 blood diseases and bleeding disorders (leukemia,
hemophilia);
 Regional malignant tumors;
 tumoral metastasis;
 diseases of oral mucosa
 Psychic diseases.
Fumatul, narcomania,
alcoolismul
Important factors that
influence the osseointegration
of implants
 The compound of the implant’s body
 The surface of the implant
 The overheating of the bone
 The contamination of the implant
 The initial stability
 The quality of the bone
 The loading of the implant
The planning of the surgical-
prosthetic treatment
The financial aspect
Every doctor must evaluate all the
benefits, the price of the all treatment
with an eye to patient’s investments for a
long time.
Reasons for presentation

 Questions concerning the condition or


problem that have led the patient to
consult the dentist
 Data collection should include the
medical condition and the current
problem
Informarea si obţinerea acordului pacientului
Evaluarea pacientului
Statusul medical general
În cadrul intervenţiei stomatologice de
implantare, recurgem la o procedură efectuată în
urma unei decizii comune, iar pacientul nu
trebuie supus nici unui risc.
În acest sens, se impune o evaluare atentă a
statusului medical general.
Societatea Americană de Anestezie
(SAA) repartizează pacienții în 6
clase:
 SAA I – pacient clinic sănătos;
 SAA II – pacient cu afecțiuni sistemice minore sau cu
factor de risc semnificativ;
 SAA III – pacient cu afecțiuni sistemice severe, fără risc
letal;
 SAA IV – pacient cu afecțiuni sistemice severe cu risc
letal;
 SAA V – pacient care necesită măsuri de resuscitare
cardio-respiratorie;
 SAA VI – pacient declarat decedat, ale cărui organe pot fi
recoltate pentru donare;
 După determinarea statusului fizic al
pacientului și repartizarea lui în clasa I
conform clasificării sus menționate,
medicul stomatolog, decide: dacă
tratamentul planificat poate fi efectuat în
condiții de plină siguranță.
 Atuncicând pacientul este
încadrat în clasa II, III, IV, V, VI
SAA, medicul se va orienta către
una din variantele propuse:
 Modificarea planului de tratament prin aplicarea
unor măsuri nonfarmaceutice de reducere a
anxietății, administrarea unei premedicaţii în
controlul anxietății și monitorizarea atentă a
pacientului în timpul tratamentului;

 Consultația interdisciplinară a pacientului pentru


prelungirea tratamentului în ambulator şi
stabilirea conduitei terapeutice pre- și
postoperatorie.
Examinarea intra- şi extraorală
Pentru a ne asigura că nu este omis
nici un factor esenţial, examenul
pacientului trebuie realizat într-un mod
standardizat.
Raportul scheletal al maxilarelor

Un raport normal scheletal


intermaxilar este considerat a fi clasa I
după Angle
In clasa a II-a există un maxilar
superior proeminent
În clasa a III-a există o mandibulă
proeminentă.
Profilul facial
Muşchii masticatori
M. pterigoid medial
M. pterigoid lateral
M. temporal
M. sternocleidomastoidian
Prin palpare se poate determina volumul şi
activitatea muşchilor masticatori.
Ne poate oferi indicii despre forţele masticatorii,
precum şi despre existenţa unor eventuale parafuncţii
cum sunt bruxismul sau scrâşnirea din dinţi.
Articulaţia temporomandibulară şi ocluzia
 Articulaţiile sunt examinate din lateral pentru
depistarea unor eventuale dureri, cracmente sau
crepitaţii care apar în timpul mişcării de
deschidere şi închidere a gurii.
 Se efectuează examenul ghidajelor ocluzale de
câte ori este posibil conform următoarelor
categorii:
 Ghidaj anterior-/canin
 Ghidaj de grup lateral
 Ocluzie deschisă anterior/ ghidaj posterior
 Contacte şi interferenţe pe partea nelucrătoare
Dinţii
 Trebuie efectuată o examinare completă a
statusului dentar, care cuprinde:
 Dinţii lipsă

 Incidenţa cariilor

 Statusul dinţilor (patologie endodontică, tipul şi


mărimea restaurărilor prezente).
 Resturi radiculare.
Pierderile de substanță dentară dură

 Evaluarea pierderilor de substanţă dură


dentară (abraziune, eroziune) poate oferi
informaţii despre-o posibilă suprasolicitare a
dinţilor, cauzată de parafuncţii sau de funcţia
masticatorie.
Alte
investigaţii
generale
Investigaţii radiologice

 Radiografia retroalveolară izometrică ortoradială


(RIO)
 Ortopantomografia (OPG)
 Tomografia computerizată (CT)
 Rezonanţa magnetică nucleară
 Modelele de studiu şi montarea diagnostică
Ortopantomografia (OPT) sau
radiografia dentară panoramică (PSA)

 Care oferă clinicianului o bună imagine de ansamblu:


 informaţii despre dinţii prezenţi,
 procesele patologice existente,
 structurile anatomice învecinate precum şi despre înălţimea
procesului alveolar.

Pe OPG se pot efectua măsurători suficient de precise ale


înălţimii osului din zona perimplantară. Acest tip de radiografie este
indicat în cazul tuturor pacienţilor care solicită tratament implanto-
protetic, ca metodă de diagnostic şi ca adjuvant în cadrul alcătuirii
planului de tratament.
 examenul câmpului operator:
- clinic
- vizual
- palpator
- instrumental
Vom examina următoarele zone:

- Fosa canină
- Sinusurile maxilare
- Apertura piriformă
Vom examina următoarele zone:

-
- Protuberanţa mentonieră
- Depresiunea fosei sublinguale
- Canalul mandibular
- Foramenul mentonier
Planificarea tratamentului
Planificarea tratamentului
The surgical-prosthetic
treatment includes two
clinical steps and a
technical one
The clinical surgical step

 One surgical step


 two surgical steps
 traditional surgery (reflecting
mucoperiosteum flap)
 flapless surgery (without mucoperiosteum
flap)
Clinical step: one surgical step
(flapless-surgery)
 Insertion of the dental implants,
appending the healing gap immediately.
The clinical step: two surgery
steps (traditional flap surgery)
 insertion of the dental implants into the
bone, applying the healing, suturing the
wound
Stages of dental
implant insertion:
Choosing the adequate devices
Disinfecting the area to be operated and covering
of patient with sterile drapes
Steps of implant insertion
Steps of implant insertion

ANESTEZIA
Osul nu are o inervaţie senzitivă proprie
(Bert, Picard, Toubae), de aceea în
implantologia orală
se practică anestezia loco-regională.
Etapele inserţiei implanturilor dentare endoosoase:

INCIZIA : se realizează la distanţă de locul de


implantare, atât mezial cât şi distal, astfel încât după
decolorarea mucoperiostului să permită o expunere a
osului cât mai favorabilă.
Etapele inserţiei implanturilor dentare endoosoase:
Decolarea mucoperiostului
Etapele inserţiei implanturilor dentare endoosoase.

 Marcarea locului de creare a neoalveolei


Formarea neoalveolei
Etapele inserţiei implanturilor dentare
endoosoase.
După punctare, se realizează operaţia de
forare primară a ţesutului osos, care se începe cu
un burghiu elicoidal de diametru 1,5-1,8 mm cu
două, trei tăişuri, apoi forarea neoalveolei
propriu -zise cu burghiurile de la setul respectiv:
Etapele inserţiei implanturilor dentare endoosoase.

 Alegerea, montarea implantului şi


suturarea plăgii
Metoda non flaplessurgery
Etapă II chirurgicală
Radiografie de control
Descoperirea implantului

Necesită o atitudine menajantă


faţă de mucoperiost ce ar contribui
la formarea timpurie şi perfectă a
manjetei gingivo - implantare
(integrare gingivo-implantară), cu
iniţierea precoce a tratamentului
protetic.
Aprecierea stabilităţii secundare a implantelor
Etapa protetică

 Clinică

 De laborator
Alegerea lingurilor de amprentare
Aplicarea transferului
Amprentarea
Ajustarea carcasului metalic
Aplicarea şi fixarea bonturilor
protetice
Ajustarea carcasului metalic
Fixarea lucrării protetice pe
implante.
D-za: Parodontită marginală cronică
generalizată forma medie.
Edentaţie parţială intercalată la maxilarul
superior şi inferior.
Planificarea tratamentului
Extr. 21; 31; 46; 47.
Inserarea implantelor
Augumentarea defectului osos cu material
osos aloplastic
Aplicarea suturilor
Radiografia de control
Edentaţie parţială terminală la maxilarul
superior
Parodontită apicală cronică exacerbată.
Odontectomia
chiuretajul
Augumentarea alveolei
Instalarea implantului și aplicarea
abutmentului
Formarea papilei interdentare
Încărcarea imediată
Suturarea plagii se efectuiază cu fir
atraumatic de grosimia 3-4 mm.
La 7-10 zile de la intervenţie se îndepărtează firele.