Site development for anterior single implant esthetics: the dentulous site.

An inevitable loss of soft and hard tissue after tooth extraction often results in a compromised site for anterior implant esthetics. Various augmentation techniques have been advocated as corrective procedures, but these techniques are time-consuming and not always predictable. Therefore, the fundamental concept of site development for anterior single implant esthetics in the event of a failing tooth is to preserve the existing gingival and osseous tissue. This article identifies factors that affect tissue changes and describes an integration of surgical and prosthodontic approaches that can optimize the tissue maintenance in the anterior esthetic zone.

Implant dentistry education for the practicing dentist.

Contemporary standards of care, as well as ethical and legal issues, dictate the incorporation of dental implants into the general dental practice. Given the simplicity of current implant systems, most general dentists already possess the clinical expertise necessary to provide basic implant restorative services to their patients. However, due to the restricted manner in which dental implant training was propagated in the United States, and perhaps due to its foreign origins, many competent dentists seem unaware of this greatly beneficial innovation. There are a variety of educational resources available for the uninitiated dentist to gain proficiency in basic implant dentistry. The ideal education in implant dentistry provides supervised hands-on clinical training on live patients as well as didactic instruction by recognized teachers in implant dentistry. Such education may or may not be devoid of commercial bias. This paper will describe many of these opportunities.

Predictable peri-implant gingival aesthetics: surgical and prosthodontic rationales.

Bone resorption following maxillary anterior tooth extraction is common and often compromises gingival tissue levels for the implant restoration. The creation of predictable peri-implant aesthetics requires proper understanding and preservation of the osseous and gingival tissue surrounding the failing tooth. This article addresses the various factors that affect the predictability of peri-implant gingival aesthetics in anterior single-tooth replacement. The surgical and prosthodontic procedures for maintenance of peri-implant aesthetics are also presented using an ovate pontic tooth on a removable partial denture following immediate extraction and implant placement.

Immediately loaded mandibular implant bar overdenture: a surgical and prosthodontic rationale.

Classical guidelines for osseointegration include a long healing time, during which functional load should be avoided. However, the long healing period might impose an intolerable situation on some patients, especially in the completely edentulous situation. Studies on immediately loaded implant-supported prostheses in completely edentulous patients have been reported, exhibiting high success rates comparable to conventionally loaded implants. This article describes the surgical and prosthodontic procedure for the immediately loaded mandibular implant bar overdenture as well as its clinical rationale.

Maintaining and attenuating periodontal tissues for aesthetic implant placement.

Alveolar ridge resorption and soft tissue recession after tooth extraction inevitably disrupted the harmonious pre-existing periodontal complex, compromising clinicians' ability to recreate successful aesthetic restorations. Although numerous surgical procedures had been advocated for the augmentation of both the alveolar ridge and its soft tissue to ideal contours, questions remain regarding viability and predictability of these procedures. This is especially critical in the maxillary anterior region, where a the condition of the soft tissue complex and its relationship to the implant restoration and its adjacent dentition often determines the implant's success. The described technique of retaining the root remnant and inducing the proliferation of the surrounding tissue in conjunction with immediate implant placement results in the preservation of existing soft and hard tissue, thus minimizing the necessity of grafting procedures and facilitating primary flap closure during implant placement.

Flapless anterior implant surgery: a surgical and prosthodontic rationale.

Full-thickness periosteal flap surgery is often accompanied by potential marginal bone loss and/or soft tissue recession. This is critical, particularly for the single-unit implant-supported restoration in the anterior maxilla, where the harmony of the soft and hard tissue architecture is of paramount importance to the development of natural aesthetics and function. This article demonstrates a flapless implant surgery technique in the anterior maxilla for optimal aesthetic results. The indications and limitations of this procedure are also discussed.

Immediate placement and provisionalization of maxillary anterior single implants: a surgical and prosthodontic rationale.

Maintaining the existing gingival architecture of a failing maxillary anterior tooth is essential in achieving an optimal aesthetic result. Immediate implant placement has been advocated to minimize tissue loss following extraction. The incorporation of a customized temporary abutment and immediate fixed provisionalization facilitates maintenance of the gingival architecture for optimal aesthetics and eliminates the need for a removable provisional prosthesis during the healing phase. This article describes the surgical and prosthodontic approach of this procedure as well as its clinical rationale.

Effects of smoking on implant success in grafted maxillary sinuses.

STATEMENT OF THE PROBLEM: Cigarette smoking has been identified as a significant risk factor for dental implant treatment. PURPOSE: This retrospective study evaluated the effect of smoking and the amount of cigarette consumption on the success rates of the implants placed in grafted maxillary sinuses. MATERIAL AND METHODS: Sixty patients (16 smokers and 44 nonsmokers) were evaluated for the effects of smoking on osseointegrated implants placed in 84 grafted maxillary sinuses that contained a total of 228 endosseous root-form implants. Seventy implants were placed in 26 maxillary sinuses in smokers, whereas 158 implants were placed in 58 sinuses in nonsmokers. The number of implant failures and the amount of cigarette consumption were recorded. RESULTS: Of the 228 implants, 205 (89.9%) remained in function, after a mean follow-up period of 41.6 months (2 to 60 months). There was a significantly higher cumulative implant success rate in nonsmokers (82.7%) than in smokers (65.3%) (P =.027). Overall cumulative implant success rate was 76%. There was no correlation between implant failures and the amount of cigarette consumption (P >.99). CONCLUSION: Within the limitations of this study, cigarette smoking appeared to be detrimental to the success of osseointegrated implants in grafted maxillary sinuses regardless of the amount of cigarette consumption.

Maxillary sinus augmentation prior to placement of endosseous implants: A histomorphometric analysis.

The aim of this prospective study was to histomorphometrically evaluate at various time intervals the mineralization stage and process of an allogeneic-xenogeneic bone graft used in sinus augmentation procedures. One biopsy was taken from 20 patients at either 6, 8, 10, or 12 months after sinus augmentation. Immediately following the biopsy, an endosseous implant was placed into the biopsy site. This protocol provided 4 groups of 5 patients each, based on healing time following sinus augmentation. Using backscattered electron image analysis, the specimens were histomorphometrically analyzed to determine the volume fractions of residual cancellous bone, newly formed bone, soft tissue, bovine hydroxyapatite, and "remineralized" freeze-dried demineralized bone allograft (rDFDBA). "Remineralization" of DFDBA particles was observed in a few areas in all specimens. Polarized light microscopy showed that only the 12-month biopsies had a predominance of lamellar bone formation. The area within the biopsies that represented the residual alveolar ridge consisted of 32.6% +/- 8.6% (mean +/- SD) of bone. In the grafted area of the biopsies the volume fraction of newly formed bone at 12 months (20.7% +/- 8.3%) was significantly higher (P < .05, analysis of variance) than at 6 months (8.1% +/- 3.0%). There was no statistically significant difference between newly formed bone in the inferior, central, and superior grafted areas in all 4 time intervals. This prospective study indicates that the mineralization process of an allogeneic-xenogeneic sinus graft is incomplete 6 months after the sinus augmentation procedure. New bone formation increased up to 12 months postaugmentation; however, it remained lower than the volume of residual bone.

Clinical complications of osseointegrated implants.

STATEMENT OF PROBLEM: There is no comprehensive review of the literature that identifies the complications reported in clinical dental implant studies. PURPOSE: This article attempted to determine the types of complications that have been reported and to provide data regarding their frequency. METHODS: All available clinical studies from 1981 to 1997, published in English or with English abstract, that presented success/failure data regarding implant treatment were evaluated to determine the types of reported complications and to quantify implant loss as it relates to type of prosthesis, arch, time, implant length, and bone quality. RESULTS: Greater implant loss occurred with overdentures than with other types of prostheses. There was greater loss in the maxilla than mandible with fixed complete dentures and overdentures, whereas little arch difference was noted with fixed partial dentures. Implant loss increased with short implants and poor bone quality. The time of implant loss (preprosthetic vs postprosthetic) varied with type of prosthesis. Surgical complications included neurosensory disturbance, hematoma, mandibular fracture, hemorrhage, and tooth devitalization. Initial and long-term marginal bone changes were identified. Peri-implant soft tissue complications included dehiscence, fistulas, and gingival inflammation/proliferation. Mechanical complications were screw loosening/fracture, implant fractures, framework, resin base and veneering material fractures, opposing prosthesis fractures, and overdenture mechanical retention problems. Some studies also presented phonetic and esthetic complications. CONCLUSIONS: Although the literature presents considerable information on implant complications, variations in study design and reporting procedures limited the available data and therefore precluded proper analysis of certain complications.

Clinical methods for evaluating implant framework fit.

STATEMENT OF PROBLEM: Passive fit of implant-supported-prosthesis frameworks has been suggested as a prerequisite for successful long-term osseointegration. However, there are no scientific guidelines as to what is passive fit and how to achieve and measure it. PURPOSE: The purpose of this article is to discuss passive fit and to review the various clinical methods that have been suggested for evaluating implant framework fit.Methods. The dental literature was reviewed to identify the clinical methods that have been used to evaluate implant framework fit. CONCLUSIONS: The suggested levels of passive fit are empirical. Numerous techniques have been advocated to evaluate the prosthesis-implant interface, but none individually provides objective results. It is suggested that clinicians use a combination of the available methods to minimize misfits.

Fabricating a stable record base for completely edentulous patients treated with osseointegrated implants using healing abutments.

A stable record base is essential for accurate interocclusal centric relation records in a completely edentulous patient. In implant prosthodontics, several procedures have been suggested for the fabrication of a stable record base. However, these procedures necessitate removal of the healing abutments during the interocclusal record procedure and the trial denture placement, which makes the procedures tedious and time-consuming. When the implant-prosthesis interface is subgingival, the patient may also experience discomfort during these procedures. This article describes a procedure for fabricating a stable record base that uses the healing abutments, which eliminates the necessity of the healing abutment removal and its consequences. Advantages and disadvantages of this procedure are also discussed.

Modular transitional implants to support the interim maxillary overdenture.

It has been reported that for implants to become osseointegrated, they must heal in the absence of functional loads for 4 to 6 months. To address the need for undisturbed healing and patient demand for uninterrupted immediate function and esthetics, the Modular Transitional Implant and Prosthetic System has been developed. This case report describes the use of transitional implants to support a removable maxillary overdenture, including methodology and the advantages and disadvantages of the system. The histomorphometric analysis of one of these transitional implants and its surrounding osseous tissue showed a 45% bone-to-implant interface after 6 months of functional loading. The transitional implant system is a sound and economical method of immediate patient restoration that allows for the protected healing of submerged implants.

Mandibular fracture after endosseous implant placement in conjunction with inferior alveolar nerve transposition: a patient treatment report.

A patient with a severely atrophic right posterior mandible had three endosseous implants placed in conjunction with transposition of the inferior alveolar nerve. Three weeks following implant placement surgery, the patient experienced a spontaneous fracture of the mandible involving the two anterior implants. The two implants were removed, and the fracture was treated with open reduction and fixation with titanium mesh. The fracture healed, and the posterior implant integrated. This report suggests that the buccolingual and superior-inferior position of the mandibular canal can increase the possibility of mandibular fracture by increasing the size of the buccal cortical plate that is removed to expose the nerve during surgery.

Endosseous implant placement in conjunction with inferior alveolar nerve transposition: an evaluation of neurosensory disturbance.

This retrospective study evaluated neurosensory dysfunction and the implant success rate associated with 64 implants placed in 15 patients following transposition of the inferior alveolar nerve. A total of 21 inferior alveolar nerve mobilization surgeries were performed. The mean postoperative follow-up time was 41.3 months, with a range of 10 to 67 months. The effects of surgical technique and implant surface geometry on neurosensory dysfunction were evaluated by using light touch, brush stroke direction, and two-point discrimination. The implant success rate was 93.8% (60/64). The surgical technique that involved detaching the mental foramen resulted in a significantly greater incidence of neurosensory disturbance (77.8%, 7/9) than did the technique that left the bony foramen intact (33.3%, 4/12). The overall incidence of neurosensory disturbance was 52.4% (11/21).

Osseointegration: contemporary concepts and treatment.

The classical principles of osseointegration were based on a strict surgical protocol established through decades of experimental research and human clinical trials. These principles establish a sound scientific and clinical foundation for the neophyte implant surgeon. Research, however, is constantly accumulating, challenging a number of these original concepts and allowing deviation from the established protocol. It is anticipated that these changes will improve implant dentistry performance and expedite patient care. Sound clinical judgment based on experience and knowledge of the scientific literature must be exercised when deviations from the established protocol are considered.