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Once teeth are lost, their embedded bone gradually disappears because it is no longer required to support the teeth.
Removable dentures or fixed bridges usually replace the teeth and lost bone to restore appearance, speech, and mastication (chewing). As with all artificial substitutes for nature’s living tissues, there are drawbacks to artificial appliances.
Dentures reduce masticatory efficiency and can suffer from poor retention. On the other hand, bridges involve cutting away healthy teeth to provide support.
An alternative tooth replacement method is to insert implants into the jawbone to support the false tooth or teeth. Implants are tooth-root-like structures made from commercially pure titanium.
Titanium is a very inert material, and such implants may become firmly attached or integrated with the bone and act similarly to a tooth root. If an implant is placed immediately or soon after a tooth is extracted, the jawbone is preserved, and its future loss is prevented. For this reason, it is best not to delay the decision to place implants, as the bone will be lost with time
which can make the placement of implants more difficult.
However, even after a considerable bone loss has occurred, it may still be possible to place an implant, although additional bone grafting techniques may be required.
The jaws' condition will be assessed for suitability, and the treatment planned using X-ray type films, photographs, and models of the teeth. It may be necessary to take a Jaw Scan (CT) type X-ray to check the available bone's amount and position.
The final decision as to whether or not to proceed with implant placement will be made at the time of surgery and determined by the jawbone's quality and quantity.
In the lower jaw runs an important nerve that supplies sensation to the chin's lower lip and skin. Obviously, the X-ray is essential in determining this nerve's position, avoiding the slight possibility of injury, resulting in altered sensation.
It is crucial to ascertain the size and position of the air sinuses and nasal cavities before implant insertion in the upper jaw. Occasionally the implants may have to be placed slightly into the sinus or nasal cavity. Usually, this is not noticeable, but there may be a slight nasal discharge with a small amount of temporary bleeding.
Implants can be inserted in one of two ways:
Implant treatment may entail a combination of the above insertion methods, and the time required to place them will depend on the number being inserted and their position in the mouth.
The implant(s) will be placed usually under a local anaesthetic.
After the procedure, there will be some discomfort and swelling. The degree of swelling will depend upon the number of implants placed and whether additional surgical procedures were carried out. Occasionally, along with the swelling, there may also be slight bruising of the skin overlying the area, which will fade over a week.
If you are a smoker or have a pre-existing medical condition that affects soft tissue healing, the amount of swelling may be more significant. The gum tissue in the region where the implants have been placed may change appearance/colour and take on a white appearance for a short time (usually two weeks) after surgery.
After 6-10 days, once the soft tissues have healed sufficiently, the stitches may be removed. During this period, it may not be possible to wear dentures or temporary restorations. After this stage, the implants will usually be left undisturbed for up to six months to attach to the jawbone.
During this period, the implant's top may show through the gum slightly, and metal may become visible. Although this is usually no cause for concern, should it occur, please contact the practice to have the area checked.
After 3 to 6 months, a second surgical procedure may be necessary to expose the implant(s) and check for firm bony attachment. If an implant has failed to take, it can be removed, as it will not be attached to the bone. Once the implant(s) have been uncovered and firm, a post or abutment will be connected, which will support a provisional crown.
This intermediate stage will last approximately 1-2 months, allowing time for the gums to settle and form a tight attachment to the implant abutment. During this time, the abutment may become visible as the gum shrinks slightly, exposing the underlying metal.
The final teeth will be made to cover as much of the exposed metallic areas as possible, improving the final appearance. Impressions will be necessary before the construction of the final restoration.
The amount of time the treatment will require varies with the degree of difficulty and the amount of work needed. It is essential to bear in mind that the teeth have to be made individually to suit your specific requirements and mouth. This type of precision work is very time-consuming and cannot be rushed, as it must be of the highest quality.
Before fitting the finished teeth, a variable number of visits may be necessary to make fine adjustments to the teeth. Therefore, it is essential to keep your dentist informed of any travel arrangements or important engagements you may be planning and give as much notice as possible.
Fortunately, this occurs rarely, as potential problems can often be anticipated and discussed with you before treatment starts. Research shows that about 5-10% of implants may fail and although the risk is small, as, with any surgical treatment, you must be aware of the possibility.
Should an implant fail to take, it is often possible to replace it with a second implant simultaneously as the first implant is removed. Of course, it will be necessary to wait a further six months while the second new implant attaches to the bone. It is not difficult to remove the failed implant as it will be very loose. It has been shown that alcohol and tobacco consumption can reduce the rate of success. These habits also affect the rate of healing and may increase the chances of post-operative infection.
Shallow residual pockets should be monitored regularly and treated if signs of disease activity are noticed. If you are a smoker, this habit may adversely affect your periodontal health & long-term prognosis for the treatment outcome.
Therefore, you are constantly advised to quit smoking. If you are a smoker, this habit may adversely affect your periodontal health & long-term prognosis for the treatment outcome. Therefore, you are constantly advised to quit smoking.
It is important to remember that implants are not “Fit and Forget” and need the same care and attention as natural teeth. Upon completion of the treatment, it will be necessary for you to attend several recall appointments to check the implant(s) condition and adjust the bite if required.
After this, regular six-monthly appointments should be made as usual for dental check-ups.
Although the gum tissue around the implants is relatively resistant to infection, you should still keep your regular hygiene appointments as a build-up of plaque will cause problems and possible bone loss from around your implants. This could result in their eventual failure.
The frequency of hygienist visits will depend on your standard of oral hygiene. Long-term maintenance of the implant and crown will be required, as for any other standard crown.
Major maintenance may involve the replacement of the crown (not implant) due to wear and tear. Minor maintenance may include removing the crown to check the implant abutment and replacement of retention screws as required. These maintenance requirements will incur additional costs above the initial fees.
If you have residual teeth and implants, it is imperative to maintain the natural teeth' health. Should the natural teeth become infected or lost for any reason, the remaining implants could be infected or damaged by the exceeding occlusal overload.
It is also crucial to inform the surgery immediately to detect any mobility or loosening of your implant teeth. Occasionally, the small screws that help retain the crown become loose due to either heavy or abnormal biting.
This is an easy matter to rectify if caught early as it entails retightening the screws and adjusting the bite or removing the cause of the loosening. Failure to attend early will result in a possible fracture of the screw or, even worse, damage to the implant.
Please find below the details of your proposed treatment options to rehabilitate the missing tooth through the implant-supported crown.
Please read each of the following treatment options carefully, as we already discussed these choices with you during your first and second appointments.
The following restorative options will be discussed in detail, including the benefits, risks, side-effects, and complications associated with each alternative option.
A denture is a removable appliance that will restore an element of function and appearance. Although some patients are happy with such prostheses, others find that a denture may move when chewing and difficult to get used to.
A conventional bridge is where a dentist reduces the tooth or teeth adjacent to the gap and then uses them to support the fixed bridge.
A resin-retained bridge is where a false tooth is glued to one or both of the teeth next to the gap via a metal wing—these bridges are mostly considered long-term temporary and are less well suited to replacing teeth.
The nature of dental implant treatment has been discussed with you at the practice and in writing above. A few animated videos and photographs of completed implant cases have been demonstrated to give you a realistic idea of the treatment's possible outcomes.
Following tooth loss, different and alternative options and procedures are recommended by your dentist to replace your missing tooth and to restore appearance, speech and chewing comfort.
Although it may sound more time-consuming and more costly, dental implants, as discussed earlier, offer a few advantages of more long-term stability and less invasiveness to the adjacent tissues and teeth. Like a tooth root, a single titanium implant is firmly attached or integrated into the jaw bone.
Animplant could be placed immediately or soon after a tooth is extracted to preserve the jaw bone. In cases of residual acute infection, a delayed surgical approach is preferred to minimise the infection risk. In some instances, as a result of bone loss, additional bone grafting is requiredbefore the dental implant placement.Following the treatment, you will have long term reviews with both your dentist and your hygienist.
At the time of your consultation phase,diagnostic x-rays,e.g. CBCT Scan, is requested, and study models are taken to confirm that treatment possible.
Under strict sterile conditions and local anaesthetic, the bone topography will be assessed, following which your implant will be placed and covered again. You will be then reviewed within two weeks for the control of tissue healing and possible suture removal.
When the bone graft has healed and the placed implant has integrated, an appointment is made to commence the process of implant restoration. Under local anaesthetic, the implant may be exposed, and a healing collar called healing abutment is placed on the implant. The technique indicated abutments (posts), and a provisional crowncould be inserted on the implant at this stage.
To modify the soft tissue healing, immediate provisional restoration may be placed to optimisethe bite, colour, position, projection and shape of the definitive crown.
During the final treatment phase,the implant will be restored. An analogue or digital impression will be provided to design and fabricate the final crown.
During the maintenance phase of the implant treatment, regular hygiene visits and check-ups are planned on a quarterly or biannually basis to prevent and intervene with any possible inadvertent risk for biological or mechanical complicationaround your functional dental implants.
Upper and Lower Fixed prosthesis on 6 implants
The concept of ALL-ON 4 or 6 implants for the Straumann® Pro Arch is based on a fixed rehabilitation of removed/missing teeth utilizing immediate placement and loading of four or six dental implants with a provisional fixed bridge. This requires a careful and comprehensive treatment planning procedure encompassing CBCT radiography, sophisticated surgical procedures, and laboratory stages, converting the provisional bridge to the final full-arch prosthesis.
Based on the recent scientific literature reviews, it has been concluded that only two 2 appropriately placed posterior respective anterior implants are deemed to support a fixed prosthesis adequately and to avoid the need for undertaking any major bone graft¬ing procedures (Mericske-Stern and Worni, 2014).
Straumann® offers a comprehensive portfolio for the treatment of edentulous patients – a task that often remains a challenge considering the expectations and clinical limitations involved. Here, we can help you evaluate and offer the right solution – be it removable or fixed restorations and straightforward or advanced indications.
Please refer to the following links from the Straumann® official patient site to access dental implant patient brochures and videos about the following subjects:
1. A solution for everybody:
2. Procedures from diagnosis to aftercare:
3. Main benefits:
4. Other frequently asked questions:
One of the key factors in the long-term success of dental implants is the maintenance of healthy tissues around them. A cause-effect relationship between bacterial plaque accumulation and the development of inflammatory changes in the soft tissues surrounding dental implants has been shown.
The existing scientific evidence demonstrates a direct association between oral microbiota and bacterial peri-implant inflammatory lesions in the form of Peri-implant mucositis or peri-implantitis. Peri-implant disease is a collective term for inflammatory reactions in the surrounding tissue of functioning implant.
Peri-implant mucositis is a term describing reversible inflammatory reactions in the surrounding soft tissue of functioning implant, while peri-implantitis refers to inflammatory reactions with loss of bone supporting functioning implant.
Peri-implantitis" have been defined as a progressive inflammatory bacterial- infectious process deteriorating and destructing the supporting soft and hard tissues around functional osseointegrated implant eliciting bacterial, clinical and radiographic signs and symptoms e.g. bleeding and suppuration.
In both experimental research and human trials, it has been demonstrated that prolonged accumulation of bacterial plaque over a long period of time, may develop the reversible nature of "peri-implant mucositis" into the irreversible "peri-implantitis" rendering such complications either untreatable (failing) or amenable to treatment (ailing).
The disease of peri-implant mucositis has been shown to occur in about 80% of subjects with endosseous dental implant (50% of sites). The implementation of non-surgical mechanical and adjunctive use of local/systemic antimicrobials therapy to reduce the inflammation has been proved to be effective in the resolution of peri-implant mucositis lesions, but unpredictable in the effective treatment of advanced peri-implantitis lesions with a prevalence of 12-40% of sites, in 28%-56% of individuals.
Identified associated risk indicators may include: poor oral hygiene, history of periodontitis, uncontrolled diabetes and heavy smoking, coupled with compromised host tissues or immune response. The primary objective of surgical treatment in peri-implantitis is to get access to the implant surface for debridement and decontamination in order to achieve resolution of the inflammatory lesion.
Therefore, the above-mentioned risk factors should be monitored, and kept under optimal control. The standard of oral hygiene should be reinforced and general health status of the periodontal tissues around the remaining teeth should be monitored during the maintenance phase.
Shallow residual pockets should be monitored regularly and treated if signs of disease activity are noticed. If you are smoker this habit adversely affects your periodontal and peri-implant health & long-term prognosis for the treatment outcome. Therefore, you are constantly advised to quit smoking.
The Guarantee for your dental implant does not cover failure due to factors mentioned above and does not include failure due to illness, misuse or accidents.
Our clinic undertakes to warrant implant-supported crowns, bridges and prostheses against mechanical failure for two years subject to the following:
Implants are guaranteed once for a year after insertion after which patients may opt for dental insurance available through an insurance service. The guarantee is subject to your compliance with the highest standard of oral hygiene and regular attendance for maintenance and reviews recommended every 4 months. Failure to do so will render any guarantee void.
Therefore, we strongly recommend all of our patients who have received implant treatment to undertake radiographic and other investigations on an annual basis to review the stability of the implant.
Image left: LOCATOR® on two dental implants.
Image Right: Bar with pre-fabricated individualized parts on four dental implants
Over-denture is a favourable and straightforward prosthetic treatment modality for elderly patients. There are fewer implants involving limited traumatic surgical invasion, and fewer clinical chairside and financial resources are required. There are instances where the provision of the conventional implant-supported fixed prosthesis (ISFP) is not clinically feasible due to the extensive atrophied residual alveolar bone where only a few implants could be placed in the front region of jaws rendering provision of implant retained overdentures (ISOD) a viable and predictable treatment modality. This alternative also facilitates the replacement of lost hard and soft tissue, especially in patients with congenital/acquired defects, to improve aesthetic, phonetics and avoid food entrapment.
Most of the old patients often ask for better prosthesis stability, particularly in the lower jaw. In patients with compromised manual dexterity, overdentures would be less demanding for the practice of self-performed plaque control.
Soft tissue complication due to the adverse effect of mucosal coverage, initiating or accentuating severe gagging reflex, patient intolerance to dentures due to psychological/physiological reasons in some cases together with requirements for higher maintenance involved are some of the inherent back draws which may render the provision of IS & IR OD design less appropriate in some individuals. In some cases, inadequate restorative space over the abutments renders the OD bulky what is not acceptable for some patients. To avoid this problem, the technician may reduce the denture's acrylic body over the abutments, which render the construction less resistant to fatigue fracture. In the case of the very well preserved alveolar ridge, the patient may not benefit from specific advantages of overdentures, and an ISFP may be a more appropriate option.
The inherent problems such as divergent and buccally directed implant alignment, long teeth, open interdental spaces and incongruent implant distribution/ tooth position render the provision of maxillary ISFP rather challenging. To address the aesthetical requirement for such morphological discrepancies, gingival-mask (epithesis), as well as buccal flanges for ISFP (Mericske-Stern et al. 1998b), has been satisfactorily fabricated.
The optimum implant placement in overdenture cases is more consistent with the available bone quality and quantity. The denture base also facilitates phonation by restoring the phonetic zone. Some literature reports a higher survival rate (stability) for the OD than for the actual implants. They also reveal that the mandible survival rate is more favourable than the maxilla, where failures are mainly related to poor bone quality, short implants, and long lever arms. The different anchorage systems of overdentures (balls, bars, and magnets, single attachments) do not seem to influence the implant failure rates (Jemt et al. 1996).
Naert et al. (1997) reported a cumulative success rate of 97% in their 9-year longitudinal study for the IROD. There was no difference observed in SR for the mandibular IROD, whether the two implants were connected by a bar or left individually. It should be borne in mind that these data relate to the IROD, where OD is mucosally supported in the distal areas.
The increasing demand for the fabrication of maxillary IR/S OD suggests a strong need for this modality of therapy when treating specific selected cases of the edentulous maxilla. However, the provision of IR/S OD should not be considered a remedy to salvage the failing fixed prosthesis. To improve this modality's success rate, meticulous surgical protocol, well-designed rigid supra-structure supported by adequate number and size of the implants (minimum four well-distributed) is a crucial functional demand of OD in each case.
Biomechanical parameters of the implant-supported and implant-retained prostheses (IS & IR) are influenced by the design of the sub-structure, supra structure, and impression technique applied. It should be emphasized that biomechanical principles applied for IROD are very different from that of for ISOD, where four implants are connected with a rigid bar providing a semi cross-arch stabilization as it has been shown that a rigid bar (Dolder bar) on telescopic attachment provides support and stability comparable to the framework in fixed prostheses (Mericske-Stern et al. 1998b).
As there are more components (abutments, bars, clips, anchors, female retainers) involved in constructing the overdentures, more technical and clinical complications are reported requiring more service and maintenance (Taylor 1998). Denture base and underlying soft tissue deterioration are also more specific to the overdentures. Therefore, the clinician should explain the importance of the routine maintenance service and possible non-routine repairs required after the provision of overdentures in the context of the cost-benefit discussion.
Fractures and loosening of the abutments (mainly in maxilla due to non-parallel implants), retaining screws, bar clips (mainly in the mandible), female parts of ball anchors and fracture of the bar and its extension, acrylic tooth, resin, prosthesis, and framework are complications related to IR/S OD:s.
Soft tissue hyperplasia, stomatitis, soreness, and food impaction may require adjustments of the prostheses or reline of the overdenture, occlusal correction, tooth re-arrangement and redesigning of overdenture (Jemt et al. 1996). Hyperplasia has been mainly associated with the maxillary OD, while the marginal soft-tissue recession has been observed more around the mandibular OD.
Fatigue fractures, impaired phonation, and aesthetic problems are the observed complications in maxillary ISFP, requiring redesigning prostheses. At the same time, lip biting is more prevalent in conjunction with the lower ISFP. In contrast to overdentures, the need for all kind of services may decrease over time for ISFP (Jemt 1991).
The provision of IR/S-OD favours the masticatory comfort and efficiency, phonetics and aesthetics of the patient. Subjective criteria such as hygiene procedures, oral comfort, and ease of handling the prosthesis are determinant factors for patient preferences.
Comparing the patients’ experience before and after oral rehabilitation with IR/S OD reveals a higher overall satisfaction, decreasing slightly over time. This so-called “combination syndrome” due to loose maxillary conventional complete denture with anterior resorption and unstable posterior contacts is described following the provision of inter-foraminal IROD (Lechner & Mammen 1996).
The literature suggests that mandibular IROD is a predictable and successful treatment modality that improves life quality, especially in patients who have already experienced wearing their conventional dentures satisfactory and successful. Where short implants are placed due to the severely atrophied jaw, it is recommended to insert more than two implants and connect them by a rigid bar to retain and support the prosthesis with a complete denture design.
The success rate of dental implants retaining and supporting overdentures may vary but be similar to a fixed prosthesis. However, only after assessing cost/benefits, risk benefits, patients’ preferences, advantages and disadvantages of fixed contra removable option for each specific case, the application of each modality may be indicated and justified to achieve an optimal clinical outcome in the best of patients’ interests.
Maxillary alveolar/cross-arch CAD/CAM bar & mandibular cast gold bar supra-structures support upper alt. lower full-arch removable prostheses/over-dentures.
The patient's clinical appearance wearing upper and lower full arch removable prosthesis/over-denture using alveolar/cross-arch implant-supported bar supra-structure.
Maxillary mucosa-supported/retained acrylic prosthesis; mandibular partial removable acrylic prosthesis Courtesy (Dr Nico Kamosi).
As a result of tooth extraction, dental infection, trauma and postoperative bone resorption, it would be necessary to reconstruct or augment the bony ridge defect before or simultaneous to implant placement to ensure sufficient bone around the implant. The alveolar ridge may need to be restored to assure a long-lasting and stable tooth replacement utilizing dental implants.
Both the function and the aesthetics of the implant-supported teeth can be severely compromised when the supporting bone and gum is deficient. In the absence of intact bone, it is impossible to replace a lost tooth using an implant-supported crown option.
These materials are sometimes covered with a protective collagen membrane derived from porcine (pig) or bovine (cow) collagen. The membrane protects the bone graft particulates while preventing displacement and early resorption of the graft material.
Most of the collagen membranes resorb entirely by the body following the bone regeneration If you do not wish consent to having any animal-derived graft or membrane products, please inform your doctor before signing the consent forms.
Bio-Oss® is a natural bone mineral derived from bovine (cow) bone with similar micro-architecture as human bone with bone scaffolding or osseo-conductive properties promoting the blood vessels' ingrowth and bone cells which gradually integrate into the native bone completely.
Bone ceramic particulates, e.g. Vitabone or Regen®, are synthetic bone graft materials made from tri-calcium phosphate naturally present in your own bone, while it has a faster resorption profile of three to six months.
For minor bone deficiencies, guided bone regeneration may be implemented. This may involve using a membrane that acts as a biological barrier to promote bone regeneration and mineralization around the defective alveolar ridge. The barrier prevents other cells from growing into the defect whereby enables merely the bone cells ingrowth.
Guided bone regeneration or 'augmentation' procedure is performed using various techniques and materials, including human/animal-derived and synthetic products. Based on the amount of bone required, the patient's bone or a mixture of all these may be used.
Dehiscence & fenestration
Straumann® BoneCeramic granules
Localised ridge atrophy
Red staining showing newly formed bone ataugmented site with Straumann® Bone Ceramic granules (Courtesy: Melloniget al. 1995).
In the absence of bone augmentation, the bone defects resulting from trauma or extracted tooth, gum recession may be developed around the neck of the implant, which would result in the aesthetic and biological complication,especially in the aesthetic zone. Although bone grafting procedure is often very successful, some biological complications such as infection or resorption may interfere with successful graft integration and consolidation.Autogenous bone grafts can be harvested from the upper or lower arches, such as the wisdom tooth area, the chin
Straumann®Emdogain consists of amelogenin for periodontal regeneration
Straumann®BoneCeramic is used for filling and/or augmenting intraoral/maxillofacial osseous defects
Straumann®Emdogain+Straumann®BoneCeramic is indicated for:
Bone and gum augmentation can reconstruct much of the loss that follows tooth removal.
This can be carried out either before or at the time of implant placement.
Bone loss at the back of the upper jaw can make it more difficult to place implants because of the presence of the Sinus. Have a look at the Sinus Augmentation section to see how we resolve this problem.
A bone graft material is placed below the tissues with a collagen membrane to contain it.
Additional gum tissue can be harvested from the palate, where it is very thick.
The bone graft material is usually a Bovine Extract (Bio-Oss), although non-animal products are also available.
Leukocyte – Platelet Rich Fibrin or L-PRF™ is a bioactive blood clot extractedin the form of autologous platelet concentration.
Leukocytes, also known as white blood cells, are part of our immune system and responsible for creating blood clots by matrix fibrin, chemo-attracting healing cells, and producing growth factors.
Like the blood testing procedure, a little sample of own blood is collected in a couple of tubes, which are spun in a unique centrifuge System (IntraSpin™) toseparate and concentrate different blood cells types andactive proteins.
The bioactive autologous platelet concentration is placed in the surgical defect and protected to platelets/Leukocyte-released growth factors within the L-PRF scaffolding fibrin clot, promoting and enhancing natural bone regeneration.
L-PRF™ promotes many types of tissue healing. L-PRF™ forms part of the solo or combined bone replacement graft material utilised in bone reconstruction, facial medicine, orthopaedics, skin burns, diabetic ulcers and many more medical regenerative fields.
L-PRF is chemically intact with NO added human, animal, synthetic, or ingredients.
Once your body L-PRF is produced, it will directly be placed within the surgical sites.
The L-PRFpromote tissue healing by the act of platelets and leukocytes embedded in the fibrin meshwork by release high concentrations of growth factors over 14 days.
The IntraSpin™ System is anFDA-approved centrifuge system and protocol.
There are NO side-effects or complications following application of L-PRF since L-PRF is extracted from own blood, having NO additiveagents involved to increase the risk for allergy or side effects.
The L-PRF products are placed in the sinuses, extraction socket, peri-implant, dento-alveolar, maxilla-facial defects to promote tissue healing.
As reported by several evidenced publications, the use of L-PRF™ is associated with reduced postoperative inflammation, pain, discomfort, recovery time, and enhanced tissue healing.
L-PRF is a 3-D autogenous combination of Platelet Rich Fibrin derived from the patientís blood. This video provides a basic introduction to the procedure and its efficacy. This natural fibrin network is rich in platelets, growth factors, and cytokines.
This video provides an introduction, overview and review of the essential characteristics regarding L-PRF. This autologous material accelerates the body's normal healing processes and is strong, pliable and suitable for suturing. These characteristics make it an excellent choice for grafting, extraction sites and implant applications. When graft material is suspended in the fibrin matrix, handling characteristics are dramatically improved. Also, there is ample working time since L-PRF is stable at room temperature for several hours.
This video provides a step-by-step overview of the protocol for the production of L-PRF utilizing the IntraSpin System. A simplified chairside procedure results in the production of a thin, compressed layer of platelet-rich fibrin that is strong, pliable and suitable for suturing.
This video demonstrates how L-PRF™ combines with your biomaterial of choice in a predictable protocol called PRF-Block™. The biomaterial is captured into the fibrin matrix, increasing its handling and biologic proficiency.
If you have too little bone at the back of the upper jaw,a sinus augmentation can solve the problem. Sinus Augmentation makes it possible to increase the amount of bone and place implants.
We have carried thousands of bone augmentation procedures over the past 25 years resulting in many happy patients having their implants.
This procedure aims to increase the amount of bone available at the back of the upper jaw. The sinuses occupy much of the space in this region, and the aim of this surgery is to place a graft below the sinus lining to create a greater quantity of bone at the sinus floor.
This procedure is carried out in the dental chair with a local anaesthetic. The bone-replacement graft material is allowed to heal for a period of nine to twelve months. During this period,the graft is replaced by new bone, and once it has healed, dental implants can then be placed.
Some surgeons use bone harvested from the patients' hip or jaw for this procedure. However, we have found that dental implants placed in the bone-replacement graft materialfollowing healing have the same success rates as dental implants placed in the nongrafted bone.
The use of the bone-replacement graft means that there is no need for a general anaesthetic or a hospital stay or a second surgical site and allows for a quicker recovery after surgery.
Sinus graft is a technique-sensitive procedure. The success of the procedure requires surgical and prosthodontic skills.
Despite complications such as tearing of the sinus membrane, infection of the graft, or loss of the implants, any long-term sinus complication rarely occurs.
Tolman, D., 1995. Reconstructive procedures with endosseous implants in grafted bone. JOMI 1995)
The lining of the healthy sinus is a structure with immunologic homeostasis. Bathed with mucin, lactoferrin, sIgA, which inhibits epithelial colonization of microorganisms and, in conjunction with ciliary action, maintain a sterile sinus environment. The sinus lining's reparative capacity is rapid, and it returns to a sterile state soon after sinus graft wound healing.
Misch CM. 1992. The pharmacologic management of maxillary sinus elevation surgery. J Oral Implantology. 1992
Endoscopy prior and posterior to the sinus grafting has demonstrated normal sinus function, including ciliary action. It appears that as long as the sinus graft does not extend high enough to interfere with ostium function, grafting in this area of the maxilla is not contraindicated physiologically and is generally a benign procedure.
Watzek G. et al., 1998. Anatomic and physiologic fundamentals of sinus floor augmentation. Quintessence 1998.
A review of biopsy from the sinus grafts been reported separately demonstrates that bone forms endosteally from the sinus floor with every material reported as long as a pace is maintained beneath and an intact sinus lining to form a closed wound environment.
Lazzara RJ. 1996. The sinus elevation procedure in endosseous implant therapy. Current opinion in Periodontology 1996,
Summers RB. 1994. A new concept in maxillary implant surgery. Comp ContinEduc Dent 1994
Jensen OT, Sennerby L. 1998. Titanium micro-implants retrieved from human sinus cavity bone grafts. JOMI. 1998.
The addition of osteoconductive alloplastic materials that maintain an apace above the sinus floor within a blood clot has been associated with the bone formation that ascends from the floor of the sinus several millimetres up into the graft.
Jensen OT. 1998. Treatment planning for sinus graft. The sinus bone graft, Quintessence 1998
Osteoinductive materials form new bone endosteally from the sinus floor as expected and form bone de novo within the graft depending on its osteoinductive (and osteoconductive) capacity.
Kirsch et al., 1998. Sinus graft using porous hydroxyapatite, in the sinus bone graft by Jensen., Quintessence 1998.
In general, autografts are highly osteoinductive and may be less dependent on sinus floor endosteal bone migration.
Marx RE. 1995. Osseointegration in natural bone, radiated bone, grafted bone—University of Miami Symposium Syllabus.
Materials containing BMP used in the sinus include allograft, autograft, BMP-2,7, which by themselves form the complete consequence of bone formation.
Nevins et al., 1996. Bone formation in the goat maxillary sinus induced by absorbable collagen sponge implants impregnated with recombinant human bone BMP2. Int J Perio Rest Dent 1996.
Animal studies using block autografts showed a high level of osseointegration compared to particulate autografts. Human studies?
Lew et al., 1994. A comparative study of osseointegration of titanium implants in the cortico-cancellous block and cortico-cancellous chip grafts in the canine ileum. J Oral Maxillofac Surg.1994. Intimacy of graft-vitality/fixation,consolidation/scar tissue vitality
Sinus allografts may have more late loading failure, more infections, and more stage 2 uncovering failures than other materials.
Jensen OT. Greer, R., 1992. Immediate placement of osseointegrating implants into the maxillary sinus augmented with mineralized cancellous allograft and Gore-Tex. Quintessence 1992.
Do they interfere with bone formation and osseointegration, implant fixation in the remodelling phase? vital/nonvital bone due to incomplete replacement by creeping substitution
Aspenberg et al., 1988. Rapid bone healing delay by bone matrix implantation, JOMI. 1988
The mechanical significance of this is unknown, but it probably makes fatigue failure more likely!
Frost, H., 1998. Vital biomechanics of bone-grafted dental implants. In the Sinus Bone Graft by Jensen, Quintessence 1998.
The way the various sinus grafting materials undergo angiogenesis, osteogenesis, consolidation, osseointegration, and remodelling requires more study to determine the exact mechanism of healing, establish the optimal grafting material, and further define the critical stages of healing.
Sinus lining/ endo-periosteum as the source of angioblast-osteoblast and /or Pluripotent cells and vascular capacity Summers RB. 1995. The osteotome technique: part 4- future site development. Compendium 1995.
No significant morphogenic protein or Osseo-proliferative contribution is found from the infractured sinus wall, demonstrating a more passive or osteoconductive effect.
The type of implant surface texture (rough-surface including HA-coated & TPS implants) and the material appears to be an essential variable in the bone graft setting. This indicates that in grafted bone, these surfaces may have a greater capacity to osseointegrate.
Jensen et al., 1996. Report of the sinus consensus conference of 1996. JOMI.vol. 13. 1998.
In the nongrafted setting, rough surfaces have resulted in more significant bone contact and greater torque removal capacity in the human tibia.
Carlsson L. et al. 1994. Bone response to HA-coated and commercially pure titanium implants in the human arthritic knee J Orthop Res 1994.
The biomaterial surface's chemical nature may also result from its increased capacity to bridge small gaps between the implant surface and the bone graft (up to 1mm). In contrast, machined titanium bridges osseous gaps of only 0.25 mm consistently to form intimate, early contact and then osseointegration.
Jensen JA. et al., 1993. A histological evaluation of the effect of HA-coating on interfacial Response. J Mater Sci Mater Med 1993.
However, there is no evidence to determine if rough surfaces are > favoured in the bone-graft setting and data regarding comparative success rates of the different implant surface is required.
Carlsson L. et al. 1988. Implant fixation improved by close fit :
Cylindrical implant-bone interface studied in rabbits. ActaOrthopScand 1988.
(O T. Jensen et al.1996.JOMI.vol. 13. 1998)
Consensus: Sinus graft should now be considered a highly predictable and effective therapeutic modality. Sinus graft (sinus lift), introduced by Tatum (1986) and Boyne & James (1980)
Sinus spaces are cavities in the upper jaw (Maxilla) on each side of the nose and above your upper back teeth. Specially treated donor bone is placed into these empty areas. Over a period of time, this is replaced by new bone, thus providing a bed into which implants can be fixed.
Whatever type of bone is added o the sinus, it must be left to mature before implants are placed or brought into function. Implants can be inserted after four to nine months, although occasionally, it may be necessary to wait longer.
As with other one grafting procedures, the implants are left to become firmly attached to the bone. A slightly extended healing period is commonly chosen with an average of six to nine months before a denture or crown and bridgework are fitted. However, all bone grafting is unique to each individual, and this information is for guidance only.
At the time of the procedure: If any infection is found or a tear in the sinus lining occurs, it may be necessary to discontinue the procedure.
Osseointegration is a process by which a clinically asymptomatic rigid direct fixation between an implant and surrounding living bone is achieved and maintained under functional loading (Zarb& Albrektsson 1991).
One of the key factors in the long-term success of dental implants is maintaining healthy tissues around them.
Biological factors contributing to implant failures can be divided into endogenous (systemic and local) and exogenous (operator-related & biomaterial-related) factors.
Endogenous systemic factors include age & genetics, medical status of the patient, smoking.
Endogenous local factors include bone quality, quantity and anatomical location, bone grafting, parafunction & biomechanical loading, local immune response, presence of "adequate" attached keratinized soft tissue, and irradiation therapy (Esposito et al. 1998).
Despite changes in mineral composition, clinical investigations seem to reject the assumption of the adverse role of age in implant success (Jemt 1993). At present, there exists inadequate information on the importance of genetic factors on implant survival.
The following adverse nutritional status, general diseases and disorders have been suggested to influence the outcome of the implant treatment: bone metabolic disease (e.g. osteoporosis, osteomalacia, hyperparathyroidism & Paget's disease); rheumatic diseases (e.g. rheumatoid arthritis, Sjogren's disease, systemic lupus erythematosus); hormonal disease (e.g. diabetes, Cushing's syndrome, hyperparathyroidism); lichen Planus, PMN anomalies, delayed hypersensitivity & immunological disorders; and malabsorption syndrome.
Experimental evidence indicates that early biomechanical overloading in excess of a critical micro-motion of 100µ (Brunski 1999) may disturb an early bone apposition during the bone remodelling phase and divert the process of osseointegration to an early reversible implant fibro-integration (Szmukler-Moncler et al. 2000).
Biological complications may lead to primary early failures by interfering with the process of osseointegration or secondary late failures to maintain the achieved osseointegration.
Mechanical failures include the failures of the hardware components, e.g. fracture of the implants, coatings, connecting screws and prostheses. Iatrogenic failures may be caused by malpositioning of implants, rendering the restoration of implant impossible due to functional, technical and aesthetical complication or may be caused by violation of the anatomical structure, requiring implant explantation(Esposito et al. 1998).
Excessive surgical trauma and premature loading (iatrogenic factors) together with impaired healing ability, infection and insufficient bone volume and quality (host-related factors) are believed to be responsible for the early (47%) implant failures, while insufficient jaw volume and bone quality compromising biomechanical capability coupled with biomechanical overloading (90%), and progressive chronic marginal infection presenting as peri-implantitis (10%) are shown to have the predominant role in the late (53%) implant failures (Esposito et al. 1998).
Supra-physiological implant functional overloading exceeding 4000 during the late process of bone remodelling have been associated with implant fibrous encapsulation and late biomechanical failures (Lanyon et al. 1975). Furthermore, implant aseptic loosening is caused by supra-physiological bone strain ≥ 6,000 μέ during the implant late functional loading (Meyer et al. 2001)
An early detection of failures and remedial intervention is recommended during the treatment reviews and maintenance sessions.
The body of evidence from the recent literature suggests that poor oral hygiene, history of periodontitis, uncontrolled diabetes and heavy smoking, compromised host tissues or immune response, poor bone quality, bone grafting, irradiation therapy, parafunctional activities, the degree of surgical trauma, bacterial contamination, compromised host tissues or immune response along with excessive loading, unfavourable number, distribution, surface characteristics and design of the supporting implants to be associated with biological failures of oral implants.
Peri-implant disease is a collective term for inflammatory reactions in the surrounding tissue of the functioning implant. Peri-implant mucositis is a term describing reversible inflammatory reactions in the surrounding soft tissue of a functioning implant.
Biological complications may be described as the following:
Similar to periodontal muco-gingival deficiencies (MGD), peri-implant muco-gingival deficiencies (PIMGD)to a result of uncontrolled inadvertent gum recession around the osseo-integrated dental implants. The apical migration of the peri-implant soft tissue margin as a result of a variety of factors may cause aesthetic disturbance, exposure of the implant abutment and in advanced cases the implant head exposure.
Etiologic factors associated with peri-implant muco-gingival deficiencies:
An ideal soft tissue thickness of ≥ 2mm with the height of 3-4 mm is required to protect the implant, abutment and the margin of the restoration.
Classification of the Peri-implant soft tissue deficiencies correspond to similar biological principles in terms of extent and severityas for the periodontal MGD, and may as well follow the same compatible to the PIMGD regenerative potential:
Class I div. 1.: Vertical marginal buccal defect up to the muco-gingival junction (MGJ)
Class I div. 2.: Vertical marginal buccal defect beyond the MGJ
Class I div. 3.: Vertical marginal buccal and proximal defect
Class II div. 1.: Horizontal marginal defect without marginal bone deficiencies
Class II div. 2.: Horizontal marginal defect with bone marginal deficiencies
The prognosis for the soft tissue augmentation is determined by the extent and severity of the defect and the implant abutment dimension, position and angulation.
The implementation of non-surgical mechanical and adjunctive use of local/systemic antimicrobials therapy to reduce the inflammation has been proved to be effective in the resolution of peri-implant mucositis lesions but unpredictable in the effective treatment of advanced peri-implantitis lesions with a prevalence of 12-40% of sites, in 28%-56% of individuals.
Peri-implantitis refers to inflammatory reactions with loss of bone supporting functioning implant (Albrektsson&Isidor 1994). The disease of peri-implant mucositis has been shown to occur in about 80% of subjects with an endosseous dental implant (50% of sites).
Peri-implantitis has been defined as a progressive inflammatory bacterial- infectious process deteriorating and destructing the supporting soft and hard tissues around functional osseointegrated implant eliciting bacterial, clinical and radiographic signs and symptoms, e.g. bleeding and suppuration (Mombelli et al. 1987).
A cause-effect relationship between bacterial plaque accumulation and the development of inflammatory changes in the soft tissues surrounding dental implants has been shown (Pontoriero 1994).
The existing scientific evidence demonstrates a direct association between oral microbiota and bacterial peri-implant inflammatory lesions in the form of Peri-implant mucositis or peri-implantitis.
In both experimental research and human trials (Lang et al. 2000), it has been demonstrated that prolonged accumulation of bacterial plaque over a long period of time may develop the reversible nature of peri-implant mucositis into the irreversible peri-implantitis rendering such complications either amenable to treatment (ailing) or untreatable (failing).
Therefore, the presence of risk factors, especially the standard of oral hygiene, should be reinforced. The periodontal tissues' general health status around the remaining teeth should be monitored during the maintenance phase.
Baseline probing measurements (PIPD) and radiographs should be obtained once the implant's final restoration is processed and fitted to follow up longitudinal monitoring of peri-implant conditions.
Standardized radiographs should be taken and compared to reference radiographs taken at the time of prosthesis insertion.
The combination of Radiographic evaluation and evidence of marginal bone loss (MBL) following initial healing and bone remodelling and clinical assessment of the presence of inflammation, e.g., bleeding on probing (BOP), suppuration, and deepened Peri-Implant Pocket Depth (PIPD) os required to verify the extent and severity of relevant pathological parameters, and to diagnose the peri-implant disease.
A plethora of literature published so far represents insufficient evidence for the effectiveness of advocated treatment modalities of peri-implantitis. The synopsis of accumulated data from experimental research and clinical experience may classify such treatment strategies into 2 main categories:
The review of the literature on the various nonsurgical treatment strategies for peri-implant lesions in animal research and human studies provides evidence that most of the nonsurgical treatment modalities directed to reduce the submucosal infection may result in a short-term improvement of peri-implantitis.
The aims and objectives of surgical therapeutic strategies involved in the treatment of peri-implantitis:
The extent and quality of bone regeneration and Osseo-reintegration at the interface following the regenerative treatment of peri-implantitis lesions have been variable in various trials and case reports. This could be because the currently advocated regenerative techniques are not performed consistently according to the appropriate clinical protocols and specific indication criteria to perform sufficient debridement, elimination of the residual debris, and effective interface decontamination.
The current treatment modalities advocated in treating peri-implantitis have been reported to exert some beneficial and successful effect. However, up to the present, none of the advocated therapeutic strategies in treating advanced peri-implantitis with specific morphology, extent, and severity has proved to be the most efficacious. Incomplete debridement and surface decontamination seem to be the major obstacle to resolving the lesion and bone regeneration at the implant-tissue interface.
These findings consistently indicate that up to the present, there is no specific individual or combination treatment strategy that has yet been recognised as a gold standard approach for the treatment of peri-implantitis and that the currently available evidence does not specify the superiority of each technique in certain sub-type of peri-implantitis.
The main problems around implants come from gum disease. These can be resolved with the right treatment, provided it is delivered early enough.
Peri-Implantitis (Courtesy: Dr Alan Sidi)
The most common cause of implants failure is gum disease, known as peri-implantitis. This is caused by a build-up of plaque bacteria and leads to a loss of bone around the implant area. If this gets too severe, the implant will need to be removed.
Initially, the gum inflammation is treated with the cleaning of the implant and advice given in regard to targeting the oral hygiene to the affected areas. Repair of the bone defect can then proceed. This is carried out with a localized surgical procedure to remove all the inflamed tissue and usually to graft the bone defect that has developed around the implant.
Sometimes the crown on the implant is removed, and the implant is left buried for 6 months for optimal healing. The same crown is then re-fitted on the implant
The diagnostic procedure and interceptive treatment of destructive peri-implantitis should be attempted at the earliest stage of disease progression.
Implants with advanced extent of peri-implant osseo-disintegration and diagnosis of advanced peri-implantitis are explanted following years of function when presenting with radiographic parameter of marginal bone loss exceeding 60% of their height and coupled with clinical pocket depth of 10mm, bleeding or pus exudate on probing.
A trephine drill is piezo device is used to excise the residual peri-implant bone support downwards to the implant apex while great care is taken not to mechanically damage the implant surface and the adjacent peri-implant healthy tissue during the explantation procedure.
The residual defect is then augmented using regenerative techniques (see gum and bone augmentation procedures).