Implant surgeries to overcome anatomic difficulties / implant dentistry course/ implant dentistry course

IMPLANT SURGERIES TOIMPLANT SURGERIES TO
OVERCOME ANATOMICOVERCOME ANATOMIC
DIFFICULTIESDIFFICULTIES
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
www.indiandentalacademy.comwww.indiandentalacademy.com

CONTENTSCONTENTS
 INTRODUCTIONINTRODUCTION
 GUIDED TISSUE REGENERATION.GUIDED TISSUE REGENERATION.
 RIDGE AUGMENTATION.RIDGE AUGMENTATION.
 MAXILLARY SINUS LIFT TECHNIQUEMAXILLARY SINUS LIFT TECHNIQUE
 INFERIOR ALVEOLAR CANALINFERIOR ALVEOLAR CANAL
LATERALIZATIONLATERALIZATION
 MENTAL NERVE DISTALIZATIONMENTAL NERVE DISTALIZATION
 CONCLUSIONCONCLUSION
 BIBLIOGRAPHYBIBLIOGRAPHY

INTRODUCTIONINTRODUCTION
 The goal of modern dentistry is to restore the patientThe goal of modern dentistry is to restore the patient
to normal contour, function, comfort, esthetics,to normal contour, function, comfort, esthetics,
speech and health regardless of the atrophy, diseasespeech and health regardless of the atrophy, disease
or injury of the stomatognathic system. The moreor injury of the stomatognathic system. The more
teeth a patient is missing the more arduous this goalteeth a patient is missing the more arduous this goal
becomes with traditional dentistry. As a result ofbecomes with traditional dentistry. As a result of
continued research in treatment planning, implantcontinued research in treatment planning, implant
designs, materials and techniques predictable successdesigns, materials and techniques predictable success
is now reality for rehabilitation of many challengingis now reality for rehabilitation of many challenging
clinical situation.clinical situation.

 Various techniques to over come anatomicVarious techniques to over come anatomic
difficulties are;difficulties are;
 Guided tissue regeneration.Guided tissue regeneration.
 Ridge augmentation.Ridge augmentation.
 Maxillary sinus lift techniqueMaxillary sinus lift technique
 Inferior alveolar canal lateralizationInferior alveolar canal lateralization
 Mental nerve distalizationMental nerve distalization

Guided tissue regenerationGuided tissue regeneration
 MELCHERMELCHER

MECHANISMMECHANISM

 the principles of membrane barrier techniques are tothe principles of membrane barrier techniques are to

 acting as a duplicate surgical flapacting as a duplicate surgical flap
 also provide a tent like areaalso provide a tent like area

IndicationsIndications
 Various implant defectsVarious implant defects
 FenestrationsFenestrations
 DehiscenceDehiscence
 Residual intra osseous defectResidual intra osseous defect
 Extraction socket defectExtraction socket defect

Materials usedMaterials used
 Nonresorbable
1. cellulose filter ( millipore)
2. ePTFE (goretex)
 Resorbable
degradation through enzymatic activity
(biodegradation) or hydrolization (bioabsorption) as a
cellular response from the surrounding tissue.
they include collagen membranes, polylactic acid,
polyglycolic acid, synthetic liquid polymer, polyglactin,
calcium sulfate, acellular dermal allografts, oxidized
cellulose mesh, duramater, human periosteum, biobrain,

 Cellulose filter
Nyman
disadvantage
 ePTFE membraneePTFE membrane
structure structure
coronal border – contact coronal border – contact
inhibitioninhibition
occlusive portion occlusive portion
2 configuration 2 configuration
. Transgingival. Transgingival
. Submerged. Submerged
titanium reinforced ePTFE titanium reinforced ePTFEwww.indiandentalacademy.comwww.indiandentalacademy.com

RIDGE AUGMENTATIONRIDGE AUGMENTATION

AimsAims
 Restoration of optimum/near optimum ridge height
and width, ridge form, vestibular depth and optimum
denture bearing area
 Protection of neurovascular bundle
 Establishment of proper interarch relationship.
 Improvement of retention and stability of denture.
 Improve the patient comfort for wearing the denture.

LimitationsLimitations
 Physical condition of the patientPhysical condition of the patient
 Metabolism of the patient (healing capacity)Metabolism of the patient (healing capacity)
 Nutritional deficiencies.Nutritional deficiencies.
 Availability of adequate soft tissue coverage.Availability of adequate soft tissue coverage.
 Compliance of the patient for major surgery.Compliance of the patient for major surgery.

Graft materialsGraft materials
 Autogenous bone graft – iliac crest, rib graftsAutogenous bone graft – iliac crest, rib grafts
 Allogenic bone grafts – freeze dried cadaver bone.Allogenic bone grafts – freeze dried cadaver bone.
 Alloplastic material – hydroxyapatiteAlloplastic material – hydroxyapatite
 Metal mesh with autogenous cancellous bone.Metal mesh with autogenous cancellous bone.
 Metal mesh with hydroxyapatiteMetal mesh with hydroxyapatite


Augmentation procedureAugmentation procedure;;
1. superior border grafting1. superior border grafting
2. inferior border grafting2. inferior border grafting
3. interpositional bone graft3. interpositional bone graft
4. visor osteotomy4. visor osteotomy
5. onlay grafting.5. onlay grafting.

Superior border graftingSuperior border grafting
 DavisDavis
 Two 15 cm autogenous rib graftsTwo 15 cm autogenous rib grafts
 Secured using transosseous wiringSecured using transosseous wiring
or circummandibular wiring.or circummandibular wiring.
 The other rib graft is made intoThe other rib graft is made into
corticocancellous particles andcorticocancellous particles and
moulded around the first rib graft.moulded around the first rib graft.
 Donor site morbidity.Donor site morbidity.
 Second surgical site necessary.Second surgical site necessary.
 Continued resorption of the graftedContinued resorption of the grafted
sites.sites.
 Soft tissue dehiscence or limitationSoft tissue dehiscence or limitation

Inferior border graftingInferior border grafting
 Indicated when ridge height is less than 5-8mm andIndicated when ridge height is less than 5-8mm and
risk of pathological fracture.risk of pathological fracture.
 First described by Marx for reconstruction ofFirst described by Marx for reconstruction of
mandible following resection.mandible following resection.
 Modified by Quinn, used for augmentation of atropicModified by Quinn, used for augmentation of atropic
ridge and subsequent placement of implantsridge and subsequent placement of implants

 Supraclavicular incision fromSupraclavicular incision from
mastoid to mastoid region.mastoid to mastoid region.
 A freeze-dried allogenic cadaverA freeze-dried allogenic cadaver
mandible is hollowed out andmandible is hollowed out and
multiple perforations made into it tomultiple perforations made into it to
allow for revascularization of theallow for revascularization of the
packed cancellous bone graft. Thispacked cancellous bone graft. This
allogenic mandible will be used as aallogenic mandible will be used as a
tray. The cancellous bone graft istray. The cancellous bone graft is
harvested from the iliac crest. Theharvested from the iliac crest. The
cadaver mandible is then filled withcadaver mandible is then filled with
autogenous cancellous graft particlesautogenous cancellous graft particles
and is fixed to the inferior borderand is fixed to the inferior border
with 2-0 vicryl sutures, bywith 2-0 vicryl sutures, by
circummandibular fixation.circummandibular fixation.

ADVANTAGESADVANTAGES
 Since no surgery is done intraorally, patient's oldSince no surgery is done intraorally, patient's old
dentures can be used as transitional denturesdentures can be used as transitional dentures
 By using this technique 11 to 17 mm of boneBy using this technique 11 to 17 mm of bone
augmentation can be achieved with a resorption rateaugmentation can be achieved with a resorption rate
of only 5 per cent over the first several years.of only 5 per cent over the first several years.
 Increased bone height to accommodate implantIncreased bone height to accommodate implant
surgerysurgery
 Extraoral flap gives adequate tissue coverageExtraoral flap gives adequate tissue coverage
 Also lower one-third of the facial height isAlso lower one-third of the facial height is
increased. Esthetically better results.increased. Esthetically better results.

Interpositional Bone GraftsInterpositional Bone Grafts
 Sandwich Grafting
 During this procedure, a horizontal
osteotomy is performed, splitting of the
residual maxilla or mandible and bone
is grafted into this osteotomy gap.
 In mandible, sandwich technique is
mainly used for augmentation of the
anterior mandible, between the mental
foramina. The autogenous or allogenic
bone or hydroxyapatite grafts can be
used successfully. Delivery of the
prosthetic appliance is delayed 3 to 5
months for allowing the remodeling of
the bone. Secondary vestibuloplasty
procedures may be necessary.

AdvantagesAdvantages
 Less resorption rate than onlay grafting.Less resorption rate than onlay grafting.
 More predictable long-term results.More predictable long-term results.
 Decreased incidence of nerve paraesthesia than theDecreased incidence of nerve paraesthesia than the
visor osteotomy.visor osteotomy.
 Can be used in conjunction with osseointegratedCan be used in conjunction with osseointegrated
implants.implants.

Onlay GraftingOnlay Grafting
 Done when adequate height but inadequate width.Done when adequate height but inadequate width.
 Two techniquesTwo techniques
1.1. Oldest technique for onlay augmentation withOldest technique for onlay augmentation with
allograft, i.e. hydroxyapatite is advocated byallograft, i.e. hydroxyapatite is advocated by
Obwegeser via submucosal vestibuloplastyObwegeser via submucosal vestibuloplasty
technique. After creating a tunnel via midline, atechnique. After creating a tunnel via midline, a
putty is formed of hydroxyapatite crystals, mixedputty is formed of hydroxyapatite crystals, mixed
with saline/blood, and is injected via syringe intowith saline/blood, and is injected via syringe into
the sub-mucosal tunnel.the sub-mucosal tunnel.

 Technique 2;Technique 2; A high vestibular incision is taken toA high vestibular incision is taken to
facilitate good water tight closure and to achieve goodfacilitate good water tight closure and to achieve good
under-mining of the tissues for relaxation.under-mining of the tissues for relaxation.
Mucoperiosteal flap is reflected to expose the defect.Mucoperiosteal flap is reflected to expose the defect.
Small perforations are made in the external cortex bySmall perforations are made in the external cortex by
using small round bur to create bleeding and promotionusing small round bur to create bleeding and promotion
of clot formation and neovascularization. The graftingof clot formation and neovascularization. The grafting
material is placed/ moulded over the external cortex.material is placed/ moulded over the external cortex.
Placement of barrier membrane helps in regeneration andPlacement of barrier membrane helps in regeneration and
preservation of the graft. Scoring of the periosteum ispreservation of the graft. Scoring of the periosteum is
done before closure for proper mobilization of the flap.done before closure for proper mobilization of the flap.

Visor OsteotomyVisor Osteotomy
 AdvantageAdvantage Eighty percent ofEighty percent of
the height is maintained at thethe height is maintained at the
endend ofof 3-5 years.3-5 years.
 DisadvantagesDisadvantages
 Nerve paraesthesia andNerve paraesthesia and
dysesthesia.dysesthesia.
 Need for hospitalization.Need for hospitalization.
 Donor site morbidity.Donor site morbidity.
 Inability to wear the denturesInability to wear the dentures
for 3 to 5 months followingfor 3 to 5 months following
surgery.surgery.

Sinus lift techniqueSinus lift technique
 Hilt Tatum.Hilt Tatum.

IndicationsIndications
 Implant placement in areas of insufficient bone volumeImplant placement in areas of insufficient bone volume
or decreased interarch space.or decreased interarch space.
 Oroantral fistula repair.Oroantral fistula repair.
 Alveolar cleft reconstruction.Alveolar cleft reconstruction.
 Le Fort I down fracture with interpositional grafting.Le Fort I down fracture with interpositional grafting.
 Cancer reconstruction for craniofacial prostheses.Cancer reconstruction for craniofacial prostheses.

ContraindicationsContraindications
GENERAL MEDICAL CONTRAINDICATIONSGENERAL MEDICAL CONTRAINDICATIONS
 Radiation treatment to the maxillary region.Radiation treatment to the maxillary region.
 sepsissepsis
 Severe medical fragility.Severe medical fragility.
 uncontrolled systemic diseaseuncontrolled systemic disease
 excessive tobacco abuseexcessive tobacco abuse
 excessive alcohol or substance abuseexcessive alcohol or substance abuse
 Psycophobias.Psycophobias.

LOCAL FACTORSLOCAL FACTORS;;
 maxillary sinus infectionsmaxillary sinus infections
 chronic sinusitischronic sinusitis
 alveolar scar ablationalveolar scar ablation
 odontogenic infectionsodontogenic infections
 inflammatory or pathologic lesionsinflammatory or pathologic lesions
 severe allergic rhinitissevere allergic rhinitis

 Original methodOriginal method

BenefitsBenefits
 Reconstruct the highly atrophic posterior maxillaReconstruct the highly atrophic posterior maxilla
 Replace the patient's removable prosthesisReplace the patient's removable prosthesis
 Stabilize the anterior residual dentition byStabilize the anterior residual dentition by
reconstructing the entire archreconstructing the entire arch
 Reduce the continuous progressive atrophy of theReduce the continuous progressive atrophy of the
posterior alveolar ridgeposterior alveolar ridge

ComplicationsComplications
 Dehiscence with loss of the graft material
 Dehiscence with exposure of the barrier membrane
 Infection
 Potential loss of implants

 Gaber et al did a study on potential alterations ofGaber et al did a study on potential alterations of
voice quality following sinus elevation For thevoice quality following sinus elevation For the
majority of patients, slight changes of the voicemajority of patients, slight changes of the voice
pattern are of no importance. However, for voicepattern are of no importance. However, for voice
professionals, whose voices have become part of theirprofessionals, whose voices have become part of their
distinctive profession or trademark, minimal changesdistinctive profession or trademark, minimal changes
may have dramatic consequences. This specific groupmay have dramatic consequences. This specific group
of patients, such as speakers, actors and singers,of patients, such as speakers, actors and singers,
depend on the particular quality and timbre of theirdepend on the particular quality and timbre of their
voice for their livelihood.voice for their livelihood.

 In conclusion, sinus lift surgery appears to be a safe,In conclusion, sinus lift surgery appears to be a safe,
predictable evidence-based method for regeneratingpredictable evidence-based method for regenerating
the highly atrophic posterior maxilla, which does notthe highly atrophic posterior maxilla, which does not
jeopardize the individual characteristic voice patternjeopardize the individual characteristic voice pattern
of high-profile patients critically dependent on theirof high-profile patients critically dependent on their
voices for their livelihood.voices for their livelihood.

INFERIOR ALVEOLAR NERVEINFERIOR ALVEOLAR NERVE
LATERALIZATIONLATERALIZATION

INDICATIONSINDICATIONS
 Replacing removable prosthetic appliances andReplacing removable prosthetic appliances and
stabilizing the anterior residual dentitionstabilizing the anterior residual dentition
 Stabilizing the temporomandibular joint and muscleStabilizing the temporomandibular joint and muscle
balance or overall tone, as reconstruction of thebalance or overall tone, as reconstruction of the
stomatognathic sys-tem is achievedstomatognathic sys-tem is achieved

LIMITATIONSLIMITATIONS
 These procedures are technically difficult and therefore not suitedThese procedures are technically difficult and therefore not suited
for every doctor.for every doctor.
 Implant practitioners who have the clinical experience, anatomicImplant practitioners who have the clinical experience, anatomic
knowledge, and ability to treat potential interoperative andknowledge, and ability to treat potential interoperative and
postoperative complications are the only ones equipped to performpostoperative complications are the only ones equipped to perform
these procedures.these procedures.
 Nerve damage is a significant risk of the procedures. Both theNerve damage is a significant risk of the procedures. Both the
surgical manipulation of the neurovascular bundle and the overallsurgical manipulation of the neurovascular bundle and the overall
surgical procedure can cause postoperative nerve deficits.surgical procedure can cause postoperative nerve deficits.
 Each patient should be advised of the risk for permanent nerveEach patient should be advised of the risk for permanent nerve
deficits, which include anesthesia, paresthesia, dysesthesia, anddeficits, which include anesthesia, paresthesia, dysesthesia, and
hyperesthesia.hyperesthesia.
 Fracture of the mandible, although rare, is also a risk. The vastFracture of the mandible, although rare, is also a risk. The vast
majority of these patients have advanced degrees of atrophy in thismajority of these patients have advanced degrees of atrophy in this
area of the mandible.area of the mandible.

NERVE ANATOMYNERVE ANATOMY
 SolarSolar documenteddocumented TwoTwo different types ofdifferent types of
intraosseous path of the mental nerveintraosseous path of the mental nerve

DISTALIZATION OF THE MENTALDISTALIZATION OF THE MENTAL
NEUROVASCULAR BUNDLENEUROVASCULAR BUNDLE

CONCLUSIONCONCLUSION
 Patients undergoing these procedures usually displaysPatients undergoing these procedures usually displays
post operative neurologic deficiency. Periodicpost operative neurologic deficiency. Periodic
assessment of these patients are atmost important.assessment of these patients are atmost important.
Without the benefits of CT scans and threeWithout the benefits of CT scans and three
dimensional reformatted imaging, these techniquesdimensional reformatted imaging, these techniques
are difficult, if not impossible, to perform. However,are difficult, if not impossible, to perform. However,
this technology has made these procedures a viablethis technology has made these procedures a viable
option when performed by a skilled andoption when performed by a skilled and
knowledgeable surgeon in appropriately selectedknowledgeable surgeon in appropriately selected
cases.cases.

BIBLIOGRAPHYBIBLIOGRAPHY
 Charles A.Babbush: Dental Implants The Art andCharles A.Babbush: Dental Implants The Art and
Science.Science.
 Carl. E. Meish – Implant dentistryCarl. E. Meish – Implant dentistry
 Block Kent Guerra: Implants in DentistryBlock Kent Guerra: Implants in Dentistry
Essentials of Endosseous Implants for MaxillofacialEssentials of Endosseous Implants for Maxillofacial
Reconstruction.Reconstruction.
 Block: Color Atlas of Dental Implant Surgery.Block: Color Atlas of Dental Implant Surgery.
 Neelima Anil Malik: Textbook of OralNeelima Anil Malik: Textbook of Oral
Maxillofacial SurgeryMaxillofacial Surgery
 Jensen: The Sinus Bone Graft.Jensen: The Sinus Bone Graft.

 Ellegaard et al; Implant therapy involving maxillary sinus lift inEllegaard et al; Implant therapy involving maxillary sinus lift in
periodontally compromised patient; Clin Oral Impl Resperiodontally compromised patient; Clin Oral Impl Res
1997;8;305315 .1997;8;305315 .
 Charles A.Babbush ; Transpositioning and repositioning theCharles A.Babbush ; Transpositioning and repositioning the
inferior alveolar and mental nerves in conjunction with endostealinferior alveolar and mental nerves in conjunction with endosteal
implant reconstruction;implant reconstruction; PeriodontologyPeriodontology 2000,2000, Vol.Vol. 17, 1998,17, 1998,
183-190183-190
 Gabor et al: Effects of sinus lifting on voice quality: Clin. OralGabor et al: Effects of sinus lifting on voice quality: Clin. Oral
Impl. Res.Impl. Res. 1414, 2003 / 767–774, 2003 / 767–774
 Eliaz Kaufman: Maxillary Sinus Elevation Surgery: AnEliaz Kaufman: Maxillary Sinus Elevation Surgery: An
Overview;Overview; j Esthet Restor Dent 2003;j Esthet Restor Dent 2003; 15:272283.15:272283.

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