Surgical considerations in the edentulous patients
for implant installation
Dept. of OMFS, School of Dentistry
Chonnam National University
2007.4.7
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Considerations in Edentulous Patients
1. General health
2. Anatomical condition
- Jaw relation
- Interarch space
- Remaining bone (morphology, quality)
- Anatomical structures
- Soft tissue condition
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Considerations in Edentulous Patients
3. Biomechanics
4. Esthetics
5. Oral hygiene maintenance
6. Treatment period
7. Cost
8. Prosthetic plan
9. Surgical skill, etc
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General Health Condition
DM, hypertension, CV, pulmonary, liver, renal diseases, etc.
Medical consultation
Treatment plan
: Minimial pain, cost, treatment period
Simpler operation
Long-term successful, simpler implant prostheses
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Radiographic Examination
Panorama, Lateral cephalo, CT taking
Pathology
Anatomical structure
: Mx. Sinus, mandibular canal, etc.
Ridge shape or quality
Available bone height & width, etc.
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Diagnostic Cast
Jaw relation
Degree of bone resorption
Vertical dimension : space for implant prosthesis
Wax-up, surgical stent
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Surgical Stent & Temporary Prosthesis
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Anatomical conditions
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Resorption Pattern of Edentulous Jaws
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Jaw Relation
Cl II
Cl I
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Correction of Jaw Relation
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Correction of Jaw Relation
Distraction Osteogenesis
Wrong vector control
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Correction of Jaw Relation by DO
Post-op 2 yrs
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Correction of Jaw Relation
04.6.12.
06.9.7.
Post-op 2 yrs
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Interarch Space
Biomechnics
Esthetics
Funtions : mastication, phonation
Prosthetic plan
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Biomechanic Considerations
Crown/implant ratio
Cantilever
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Prosthetic Plan
Function
Biomechanics
General, local condition
Cost
Surgical skill, etc.
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Overdenture
Cantilever
Leverage
Attachment,
etc.
Arch shape
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Mental Foramen
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Overdenture
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Temporary implant
2 , 4
ball type & short head for overdenture
Temporary denture ( )
Temporary fixed bridge
Soft diet (about 6wks)
If osseointegration
- Temporary implant removal
by using Trephine bur
- Submerge after removal
of the head
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Temporary implant
Intraoperative photographs
: Both sinus elevation with iliac PMCB bone,
onlay block bone graft, & temporary implant installation
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Temporary implant
Temporary implant & overdenture
Preop
Postop +1mo
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Types of Bone Quality
- Lekholm & Zarb, 1985
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Physiologic Changes of Edentulous Jaws
Osteoporosis
Fatty marrow
Loose trabecula
#36
#36
#36
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Osseointegration
in Poor Bone Quality
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Table 1. Percentage of bone-implant contact ratio in cortical bone of tibia (%)
Control
RBM
HA
SLA
Mean
SD
Minimum
Maximum
16
10
8
6
75.9
87.1*
95.4**
86.0*
11.9
5.3
2.9
3.5
69.5
83.3
93.0
82.4
82.2
91.0
97.8
89.7
*; p<0.05, **; p<0.01, SD; standard deviation
Table 2. Percentage of bone-implant contact ratio in marrow space of tibia (%)
Control
RBM
HA
SLA
Mean
8
8
6
8
29.6
36.7
76.1**
45.1
**; p<0.01, SD; standard deviation
SD
Minimum
Maximum
5.4
10.3
15.0
15.0
25.1
28.0
60.4
32.5
34.1
45.3
91.8
57.6
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Implantation in Poor Bone Quality
Minimal drilling
Use of osteotome
Implants
: Wide & long diameter
Rough surface
Threaded, self-tapping implant
Number of implant
Bone (PMCB) graft
Longer healing period
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Anatomic Structures of Edentulous
Maxilla and Mandible
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Anatomic Structures of Edentulous
Maxilla
Nasal cavity
Maxillary sinus
Incisive foramen
Greater palatine foramen
Peri-implant bone thickness
: more than 1 mm
Alveolar bone width
: more than 5~6 mm
Vertical alveolar bone height
: more than 10 mm
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Resolutions of Anatomic Limitation
in the Anterior Maxilla
Narrow alveolar & Vertically atrophic ridge
Small diameter fixture
Osteoplasty
GBR
Ridge expansion osteotomy (REO) procedure
Split crest (ridge splitting) technique
Veneer (saddle) bone graft
Antral-nasal inlay graft
Interpositional bone graft with Le Fort I osteotomy
Alveolar distraction
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Ridge Expansion Osteotomy (REO)
Indications
Cancellous maxilla
Narrow ridge, wider than 4 mm in B-P width
(Ridge expansion effect : 1 ~ 2 mm)
Immediate implantation
Incomplete healed socket
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Ridge Expansion Osteotomy
Intraoperative photographs
Radiographs progression
: REO on anterior maxilla with chin bone graft
Pre-op
Post-op 4mo
Post-op
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Ridge Expansion Osteotomy
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Split Crest Technique
Indication
Narrow alveolar ridge
: wider than 3 mm in B-P width
(Ridge expansion effect : 3 ~ 5 mm)
Healing period : 4 ~ 5 months.
Provisional occlusal loading : 3 ~ 5 months
Success rate : 85 ~ 98 %
Marginal bone loss : 0.5 ~ 1.5 mm
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Split-Crest Technique
Intraoperative photographs
: Split-crest tech. with Mx tuberosity bone graft
Radiographs progression
Pre-op
Post-op
Post-op 1.5 yrs
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Veneer Bone Graft
= Veneer onlay bone graft
Lateral onlay bone graft
Lateral augmentation
Indication
Narrow ridge, less than 3 mm in B-P width
Peri-implant defects (fenestration, dehiscence)
(Ridge expansion effect : More than 3 ~ 4 mm)
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Saddle Bone Graft
Indication
Horizontal and vertical atrophic ridge
: For horizontal and vertical augmentation
(Ridge augmentation effect : 3 ~ 10 mm)
Choice of graft material
Block bone : Chin, ramus, ilium
: Significant less resorption
than particulate bone
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Saddle Bone Graft with Iliac Bone
Post-op 5mon
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Iliac block bone graft & Lt sinus elevation
Preop
Implant installation (Iliac BG + 5 months)
Implant + 4 months (Iliac BG + 10 months)
Postoperative Radiographs
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Resolution of Anatomic Limitations
in the Posterior Maxilla
Vertically Atrophic Ridge
Short, wide diameter fixture
Onlay bone graft
Interpositional bone graft with Le Fort I osteotomyt
Zygomaticoalveolar implant
Mx sinus floor elevation
: OSFE, BAOSFE, and subantral bone graft
Vertical alveolar distraction (?)
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Protocol of Maxillary Sinus Elevation
Residual bone height
Methods
Timing of installation
> 9 mm
OSFE (0-2mm)
Simultaneous
9 ~ 7 mm
BAOSFE (2-4mm)
Simultaneous
7 ~ 3 (5) mm
One-step lateral window
Simultaneous
< 3 (5) mm
Two-step lateral window
One-step with block bone
2nd step 3 - 4 mo later
Chonnam Univ. Hospital
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(Oh)
One-Step Sinus Elevation
( Window Technique)
Indication
3(5) ~ 7 mm in residual bone height
: Use particulated bone graft
Less than 3 mm in residual bone height
: Use block bone graft
Stable initial implant fixation
No maxillary sinus infection
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One-Step Subantral Bone Graft
2005. 5. 23.
Extraction on #13-23, 35-47
Both sinuses elevation with both ramal bone graft
Implant installation on #12i-16i, 22i-26i
Temporary implant (4X) installation
2005.8.5.
Implant installation on #32i-37i,42i-47i
Temporary implant (4X) installation
Residual bone H.: 3mm
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One-Step Subantral Bone Graft
: Sinus elevation with ramal & Mx tuberosity B/G, temporary implant
Implant installation on the lower jaw & temporary implant
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One-Step Subantral Bone Graft
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One-Step Subantral Bone Graft
Post-op 1.5 yrs
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Two-Step Subantral Bone Graft
Indication
Less than 3 mm in residual bone height
Unstable initial implant fixation
Maxillary sinus infection
Additional bone graft (onlay graft)
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Two-Step Subantral Bone Graft
Pt: Kim 0 0 (53/M)
PMH: HTN & DM (Med. for 10 yrs)
Imp: Edentulous state on #14-17, #24-27, #37-47,
& chronic severe periodontitis
HxPi: 04. 2.17. OMS visit
04. 2.23. Ext of #11-13, 21-23,
implant on #32i-36i, #42i-46i,
onlay bone graft on Rt alveolous,
& both sinus elevation with chin bone
04. 8. 7. Implant on #12i-16i, #22i-26i
05. 1.20. 2nd Surg.
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Two-Step Subantral Bone Graft
Both sinus elevation with chin bone,
Onlay bone graft on Rt alveolous, Implant on #32i-36i, #42i-46i,
Post-op 5mo
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Two-Step Subantral Bone Graft
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Post-op 1.5 yrs
Two-Step Subantral Bone Graft
Post-op 1.5 yrs
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Anatomic Structures of Edentulous
Maxilla and Mandible
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Anatomic structures of edentulous
mandible
Mental nerve
Inferior alveolar nerve
Atrophic ridge
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#35i
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Resolutions of Anatomic Limitation
in the Mandible
Narrow & Vertically Atrophic Ridge
Small diameter fixture
Osteoplasty
GBR
Ridge expansion osteotomy (REO) procedure
Split crest (ridge splitting) technique
Veneer (saddle) bone graft
Vertical alveolar distraction
Inferior alveolar nerve repositioning
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Osteoplasty
Pt: La 0 0 (71/F)
Imp: Full edentulous state on both jaws
HxPi: 04. 6.17. Implant on #32i,33i,42i,43i
for bar-retained overdenture
04. 11.2. 2nd Surg.
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Osteoplasty
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Osteoplasty
Post-op 2 yrs
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Inferior Alveolar Nerve(IAN) Repositioning & DO
Pt: Kim 0 0 (46/F)
Imp: Atrophic ridge on both side of lower posterior,
Edentulous state on # 34-37
HxPi: 95. Extraction of #17, 34-37, 44-47
05. 1.12. Rt IAN reposition,
implant on #44i, 45i, 46i,
& Lt alveolar DO device delivery
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IAN Repositioning & DO
Dental CT Findings : 2005. 1. 6. (pre-op)
: 4mm, 5mm
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IAN Repositioning & DO
Intraoperative photographs
: Rt IAN transposition, & Lt alveloar DO device delivery
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IAN Repositioning & DO
Implant prosthesis
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IAN Repositioning & DO
Intraoral photographs progression
Pre-op
Post-op 1.5
yr
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Summary
In the edentulous patients,
1. Many factors, such as jaw relation, inter-arch space, remaining bone,
anatomical structures, soft tissue and so on, should be considered.
2. In old patients, general condition is primarily considered.
The simple and safe implantation techniques are usually recommended.
3. In the anterior region, the esthetic is primarily considered.
4. In the posterior region, the biomechanics is primarily considered.
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