Implants in orthodontics 1 /certified fixed orthodontic courses by Indian dental academy

Implants
in orthodontics

www.indiandentalacademy.com

INDIAN DENTAL ACADEMY
Leader in continuing dental education


CONTENTS
1.
2.
3.
4.

Introduction .
Historical background .
Classification of implants .
Diagnosis & treatment planning
implants .
5. Bone physiology & metabolism .
6. Principles - Osseointegration .
7. Biomaterials in implants .

for

8. Biomechanics in implant dentistry.
9. Complications with implants .
10.Uses of implants - Medical .
- Orthodontic .
11. Conclusion .


INTRODUCTION


 For centuries man has dreamt of replacing
missing teeth with artificial substitutes that
restore the normal function, comfort,
esthetics, & speech.
 Implants make that dream come true .


With implants we enter a new era of dental
care & oral rehabilitation. They increase the
treatment possibilities for patients & improve
functional results of the treatment.


HISTORICAL
BACKGROUND


Ancient implants –
Attempts to replace lost teeth with endosteal
implants have been traced to ancient Egyptian &
South American civilization.
A skull from Pre Columbian era in museum shows
an artificial tooth carved from dark stone, replaced
a lower left lateral incisor.
Implanted animal & carved ivory tooth cited in
ancient Egyptian writings are oldest examples of
primitive Implantology.

 Earliest dental implants used, were of stone
& ivory, cited in archeological records of
China & Egypt , before the common era.
 Gold & ivory dental implants were used in
16th & 17th century.


Metal implants device of gold , lead, iridium,
stainless steel, cobalt alloy were developed
in 20th century.
Cobalt – chromium – molybdenum subperiosteal & titanium blade implants were
introduced in 1940s & 60s respectively &
became the most popular & successful
implants device from 1950-80 .

Exaggerated claims in the wake of long term
morbidity & unpredictability evolved into
disbelief & disinterest & even denial on the
part of organized dentistry.
These implants never really caught.


IMPLANTS
Nomenclature
&
Classification.

Implant-:
A dental implant is a device of
biocompatible material/s placed within or
against the mandibular or maxillary bone to
provide additional or enhanced support for a
prosthesis or tooth.


Parts of an implant


Gold screw
Gold
cylinder

Abutment
Cover screw
Fixture

CLASSIFICATION


Implants
Endosteal

Subperiosteal

Transosteal

Root form Plate/blade form Endodontic stabilizer


Endosteal implant
Endo – within

Osteal – bone -:
alloplastic material surgically
inserted into a residual bony ridge, primarily
to serve as a prosthodontic foundation.


 Endosteal implants comprise one broad
category of implants .
 The most commonly applicable abutment
providing modalities are endosteal.
 The endosteal implants are placed within a
fully or partially edentulous alveolar ridges
with sufficient residual bone available.


Some endosteal implants are attached to
components for the retention of a fixed or
removable prosthesis.
Other implants are equipped with an
abutment integral with the implant body,
which protrudes into the oral cavity during
healing.


Root form implant
 These are designed to resemble the shape
of a natural tooth root. They usually are
circular in cross section .
 As a general rule root form must achieve
Osseointegration to succeed. Therefore
they are placed in a functional state during
healing until they are osseointegrated .


Most of the root forms are 2 stage implants Stage 1 – is submersion or semi submersion
to permit a functional healing .
Stage 2 – is attachment of an abutment or
retention mechanism.
A root form can be placed anywhere in the
mandible or maxilla where there is sufficient
bone available.

Plate / Blade form implant
 The basic shape of plate or blade implant
is similar to that of a metal plate or blade in
cross section . Some plate blade forms
have combination of parallel & tapered
sides.
They are unique among implants in that
they can function successfully in either
osseointegration or osteopreservation mode
of tissue integration.

Plate/blade form implants


Endodontic stabilizer implants


The endodontic stabilizers function in the
osteopreservation mode of tissue integration


Subperiosteal implants
Because there is often
not enough bone in
which to place an
endosteal implant.
Dentists turned to,
placing it on & around
the bone .


Transosteal implants
Surgically invasive & technique sensitive.
These implants feature a plate that is placed
against the exposed inferior border of the
mandible with extension that pass from this
plate through symphyseal area out of the
crest of the ridge & into the oral cavity.


Ramus frame implants
Often intended
for treatment of
total mandibular
edentulism with
severe alveolar
ridge resorption.


DIAGNOSIS & TREATMENT
PLANNING


Consultation
 Chief complaint
 Patients Goals of Treatment


Clinical Examination
 Medical
examination
 Radiography
 Diagnostic Models


Diagnosis & Treatment Planning




Periodontics
Operative
Prosthodontics
– Abutment support evaluations
 New implant abutment support
– Evaluation of available bone
 Quality
 Quantity
– Choice of implant modality
 Endosteal
- root form
- plate / blade form
 Subperiosteal

 Natural implant abutment support

 Goal-oriented case presentation
– Other treatment options
– Thoroughly informed consent





Acceptance of treatment plan
Treatment
Maintenance
– Professional maintenance
 Recall examination and prophylaxis
 Early detection & treatment related complication
 Patient education

– Home care

BONE PHYSIOLOGY &
METABOLISM.


 Bone mineral is primary metabolic stores of
essential element calcium. In addition to its
obvious structural role, bones most primitive
& essential function is calcium metabolism.
 Phylogenetically the original purpose of
internal stores of mineralized tissue was to
serve as a physiologic reservoir of calcium.


Bone is a highly ordered composite of
organic matrix & inorganic material.
Osseous matrix, referred to as osteiod –
Before mineralization , is primarily collagen
fibers embedded in ground substance.
The latter is a viscous gel of water &
glycoprotein complex. It also contains
numerous organic factors ( cytokines,growth
factors)

 During
mineralization
small
crystals
of
hydroxyapatite are densely packed in an ordered
array according to collagen fiber orientation.
 Osseous tissue is formed in a number of
configuration depending on age , function &
physiologic history.
 Bones are composed of 4 microscopic tissue
types-Woven bone
-Lamellar bone
-Bundle bone
-Composite bone

Woven bone
 Highly cellular osseous tissue that is formed
rapidly , in response to growth or injury.
 Compared to mature bone it has relatively low
mineral content, a more random fiber orientation &
minimal strength .
 This serves an important stabilization role in initial
healing of endosseous implant as it is more
pliable than mature lamellar bone.
 Woven bone lacks the strength to resist functional
load.

Lamellar bone
Is the principal load bearing tissue of adult
skeleton. In adults lamellae are formed
slowly , they have highly organized matrix ,&
are densely mineralized .


Bundle bone
It is the characteristic of ligament & tendon
attachment along with bone forming
surfaces.
Bundle bone is formed adjacent to the
periodontal ligament of physiologically
drifting teeth.


Composite bone
 It is the lamellar bone deposited on woven
bone.
 Lamellar compaction of the composite bone
is an important step in achieving
stabilization of an implant during the rigid
integration process.


PRINCIPALS OF IMPLANTS.


Osseointegration
 Osseointegration is a biological concept . It refers
to the incorporation within living bone of an
inanimate (metallic component) . It is in essence
an anchorage mechanism , nothing more nothing
less.
 Osseointegration is defined as direct , structural &
functional connection between the organized vital
bone & the surface of titanium implant , capable of
bearing the functional load. – Branemark.

Osseointegration was introduced in dentistry
& orthopedics to provide an anchorage
system for the prosthesis, the use of
osseointegration has broad application –
Dental prosthesis.
Maxillofacial prosthesis.
Injured joint replacement.
Artificial limb replacement.

Besides restoration of lost tooth, implant can
be indicated as anchorage for orthodontic
movement of natural tooth .
Orthodontic tooth movement is restricted by
reciprocal forces of action / retention when
there are no fixed anchorage points in the
oral cavity, normally this is compensated for
with extraoral anchorage system.

According to Higuchi & Stalk orthodontic
forces of 150 -400 gms can be applied to
implants during orthodontic treatment which
allows tooth movement without affecting
osseointegration.


Fibrointegration

Osseointegrtion

BIOMATERIALS IN
IMPLANTS


Biocompatibility
It is defined as an appropriate response to a
material (biomaterial) within a device
(design) for a specific clinical application.


In 1960’s emphasis was placed on making
biomaterial more inert & chemically stable
within the biologic environment.
High purity ceramics of aluminum oxide,
carbon, carbon- silicon compound are
classical examples of these trends.


In 1970’s –
Biocompatibility was defined in terms of
minimum damage to the host or the
biomaterial.
In 1980’s –
Focus transferred to bioactive substrates
intended to positively influence tissue
response .

In 1990’s –
Emphasis has been on chemically &
mechanically
anisotropic
substrates
combined with growth (mitogenic) &
inductive (morphogenic) substances.


characteristics of implant material
Physical & mechanical properties –
Forces exerted on implants consists of –
Tensile
Compressive
Shear components.


Parafunction can be greatly detrimental to
longivity because of mechanical properties
like –
 Maximal yield strength .
 Fatigue strength .
 Ductility.
 Creep deformability &
 Fracture.

As bone can modify its structure in response
to forces exerted on it , implant material
must be designed to account for increased
performance of musculature & bone, in jaws
restored with implants .


Corrosion & biodegradation –
Corrosion is a special concern for metallic
materials, in dental Implantology because
implants protrude into the oral cavity where
electrolyte & oxygen composition differ from
that of tissue fluids.


Stress corrosion cracking –
The combination of high magnitude of applied
mechanical stress & simultaneous exposure
to a corrosive environment can result in the
failure of metallic implant materials by
cracking.


Toxicity –
Is related to primary biodegradation products
(simple & complex cations & anions) ,
particularly those with higher atomic weight
metals.


Metals and alloys as implants.
 Titanium
 Titanium- 6 aluminum-4 vanadium
 Cobalt- chromium –molybdenum based alloys.
 Iron –chromium –nickel based alloys.
 Ceramics & carbon –
- Aluminum , titanium & zirconium oxides.
 Bioactive & biodegradable ceramics based on
calcium phosphates.
 Polymers & composites.

CLINICAL BIOMECHANICS
IN IMPLANT DENTISTRY


The Discipline of biomedical engineering &
application of these principles to living
systems has unfolded a new era in
diagnosis,
treatment
planning
&
rehabilitation in patient care.
BIOMECHANICS


Loads applied to dental implants
Dental implants are subjected to occlusal
loads when placed in function , which may
vary dramatically in magnitude, frequency,&
duration
depending
on
patients
parafunctional habits.


Passive mechanical load
 During the healing stage because of the
mandibular flexure, contact with first stage
screw .
 Perioral forces of tongue ,cheek exert low
but frequent horizontal loads on implant
abutment .
 These may be of greater magnitude with
parafunctional oral habit or tongue thrust.

Forces
 Forces may be described by magnitude, direction,
duration & magnification factors.
 Forces acting on a dental implant are referred to
as
vector quantities i.e they possess both
magnitude & direction.
 A force applied to a dental implant is rarely
directed absolutely longitudinally along a single
axis. In fact 3 dominant clinical loading axes exist
in implants –
 Mesiodistal.
 Faciolingual.
 Occlusoapical.

Components of forces
Occlusion serves as a primary determinant in
establishing load direction.
Angled abutments also results in development
of dangerous transverse force components
under occlusal loads , in the direction of the
angled abutment.


3 types of forces –
1. Compressive.
2. Tensile.
3. Shear .
Compressive –
compressive force tends to maintain
the integrity of a bone to implant interface .

 Tensile & shear forces tend to distract or
disrupt such an interface.
 Shear forces are most destructive to implant
& / or bone when compared to other load
modalities.
 Compressive force are best accomodated.


Cortical bone is strongest in compression &
weakest in shear.
Implant body design transmit the occlusal
load to the bone. The conversion of a single
force into 3 different types of forces is
completely controlled by the implant
geometry .


 Cylinderic implants in particular are at
highest risk for harmful shear loads at the
implant to tissue interface under an occlusal
load directed along the long axis of the
implant body.
 Bone loss adjacent to cylindrical implant
and / or coating degradation results in
mechanically compromised implant.

Stress
The manner in which the force is distributed
over a surface is referred to as mechanical
stress.
The magnitude of stress is dependent on 2
variables –
1. Force magnitude .
2. Crossectional area over which force is
dissipated.

Force magnitude
 Rarely can be controlled.
 May be decreased by decreasing the
magnifiers of force –
1. cantilever length
2. off set bends
3. crown height
4. Night guards
nocturnal parafunction.

Functional cross sectional area
Defined as the surface that participates
significantly is load bearing & stress
dissipation it may be optimized by –
1. no. of implants in given edentulous area.
2. Selecting an implant geometry .
Increase in functional surface area serves to
decrease magnitude of mechanical stress.


Strain & deformation
Load applied to a dental implant may induce
deformation of both implant & surrounding
tissue.
Biologic tissue may be able to interpret
deformation or a manifestation & respond
with initiation of remodeling activity.


Impact loads
 When 2 bodies collide in a very small interval of
time relatively large reaction force develops . Such
a collision is described as impact.
 The higher the impact load greater is the risk of
implant failure & bone fracture.
 Rigidly fixed implants generate a higher interfacial
impact force with occlusion compared with natural
teeth , which possess periodontal ligament.


Force delivery & fatigue
mechanism
Duration of force may effect the ultimate
outcome of an implant system.
Relatively low magnitude forces applied
repeatedly over a long time ,may result in
fatigue failure of an implant / prosthesis.


COMPLICATIONS


Soft tissue complications
Infection
Exposure of cover screw.
Gingivitis.
Exposure of the fixture threads.


Bone complications
Progressive marginal bone loss –
1 – 1.5mm 1st yr. of surgery.
occlusal trauma.
fixture fracture.

Fixture mobility –
If fixture mobility is detected, regardless of
degree of mobility it is considered as
failure to osseointegrate.

Treatment –
Fixture must be extracted.
Possible causes of failure can be –
 During 1st stage of surgery - tissue bed damaged
by thermal changes.
 During healing phase – inflammation.
 Prior to healing – occlusal or traumatic forces.
 Progressive gingivitis – inhibits osseointegration.
 Bony thread fracture in fixture site.

IMPLANT SURGERY


Incision


Mucoperiosteum
raised

Neurovascular
bundles

Perforation of the
cortex

Preparation of the
site

Preparation of
site

Insertion of the
implant

Implants placed

suturing


Location of the
implants

Healing
abutments

Cover screws
exposed through
punch incision

Healing
abutments
inserted

Healing
abutments
removed to
reveal peri
implant cuff.

Assessment of
soft tissue
depth

Abutments

Abutments

Final abutments


USES OF IMPLANTS


CONGENITALLY ABSENT EAR


Congenitally absent ear


AURICULAR PROSTHESIS


COMBINED EXTRAORAL &
INTRAORAL PROSTHESIS


Pre-treatment

Implant with bar

Post-treatment


UNILATERAL CLEFT LIP &
PALATE


Pre-treatment

Pre-treatment

Posttreatment


OCULAR PROSTHESIS


Ocular prosthesis


NASAL PROSTHESIS


Pre-treatment

Endosseous
implant

Post - treatment

Rigid Implant Anchorage to Close
a Mandibular First Molar
Extraction Site
W. EUGENE ROBERTS,
CHARLES L. NELSON,
CHARLES J. GOODACRE,


Age = 34 year
Sex = Male
Class I mutilated malocclusion
Missing: maxillary right first and mandibular left
first permanent molars
 Treatment : Implant-supported anchorage
 Tx planning : non-extraction  to close the
asymmetric first molar extraction  unidirectional
(mesial) space closure.






Pre-treatment


$
Post-treatment


Facial implants


The use of implants for
orthodontic correction of an open
bite




Age / sex – 25 yrs./ male

 A traumatic injury to the anterior mandible.


A panoramic radiograph revealed nondisplaced
horizontal and vertical fractures of the mandibular anterior
alveolar processes.
with displacement of lower right incisors, canine, and
premolar. The lower left incisors were avulsed at the time
of trauma.



Treatment
3 implants in the mandibular central,
left canine, and premolar regions.
replace missing
teeth with a fixed prosthesis,
orthodontic correction.

Pre-treatment

TREATMENT PROGRESS
Diagnostic work-up

implants were placed
Active orthodontic treatment

vertical elastics in anterior region and left posterior
region
Toward the completion
anterior open bite closed to 2 mm
posterior interdigitation,
Class I canine & left side molars in Class I
& class II on right side.

Diagnostic set up

Post-treatment


Implants as anchorage for
molar uprighting and intrusion
W. Craig Shellhart, DDS, MS;
Maged Moawad, DDS, MPh,
MS;
Preston Lake, DMD


 Age / sex - 25yrs/ male
 chief complaint - Anterior and posterior
crossbites.
 I/o An anterior crossbite, left maxillary lateral
incisor positioned lingually.
Reduced overbite .
The left posterior teeth were in a crossbite,
maxillary arch - transverse asymmetry
mandibular first molars missing bilaterally.
 Diagnosis - (Class I skeletal, normal incisor
angulation, normal vertical relations).

Treatment plan
use of osseointegrated implants.
TPA
Mandibular second molars
to be tipped distally & intruded.
allow the placement
of single tooth prostheses bilaterally.

Use of maxillary intraosseous
implants for Class II elastic
anchorage
Nile A. Sorenson, Jr, DMD


 Age / sex - 39yr / female
 I/o maxilla –
missing - incisors & canines & 3rd molars.
moderate spacing adjacent to both mandibular
canines.
The mandibular incisors and canines were over
erupted and nearly in contact with the soft
tissue on the upper arch - accentuated curve
of Spee.
A Class II M.R left side.
The mandibular midline have shifted 2 mm to
the left.

Pre-treatment with RPD

With implant

With prosthesis


Bite opened


Bridge in place

Prediction of mandibular growth
rotation
A. Björk, Odont. Dr.


It comprised study of 100 children of each sex
covering the age period from 4 to 24 years.
The sample consists of normal children with
and without malocclusion and also children
with pathologic conditions.


A growth analysis consists essentially of three items,
each of which is clinically significant:
1. An assessment of the development in shape of
the face which, in the first place, implies changes
in the intermaxillary relationship.
2. An assessment of whether the intensity of the
facial growth in general is high or low.
3. An evaluation of the individual rate of maturation.
This is important in establishing whether puberty
has been reached and when the growth may be
expected to be completed.

Structural signs of growth rotation
1)
2)
3)
4)
5)
6)
7)

inclination of the condylar head.
curvature of the mandibular canal.
shape of the lower border of the mandible
inclination of the symphysis.
interincisal angle.
interpremolar or intermolar angles.
anterior lower face height.

Osseointegrated titanium,
implants for maxillofacial
protraction in monkeys


Large dots implants


Extra oral traction appliance


Tracings
solid lines – pre treatment
dotted lines – post treatment


Solid line – end of force application
Dotted line – after 4 weeks

Solid line – end of retention
Dotted line -10 weeks post retention


Protraction force
applied to splinted
maxillary teeth

Skeletal
remodeling &
sutural expansion


Zygomatico-temporal
suture in control animal

Zygomatico-temporal
suture in experimental
animal

Traction force delivered to
maxillary implant.
separation of
zygomaticomaxillary suture

zygomatic implant.
separation of
zygomaticotemporal &
sphenozygomaticwww.indiandentalacademy.com
suture

maxillary dentition
minimal effect on
zygomatico maxillary suture

maxillary implant.
separation of
zygomaticomaxillary suture

Forced eruption and implant
site development: Soft tissue
response
Theo Mantzikos, DMD, and Ilan
Shamus, DDS


 A nonsurgical technique for increasing the amount
of available bone for implant site development and
fixture placement is orthodontic extrusion, or
forced eruption.
 when tension is applied to the periodontal
ligament, periodontal fiber bundles are elongated,
and osteoblasts are induced to deposit new bone
in the areas of the alveolus where periodontal
attachment exists.

Pre-treatment

Bone-loss

Fixed appliance
.018 s.s with step
down bend


Keratinized gingiva
bracket placement on cementum

Vertical bone
improvement

CONCLUSION


The last decade has seen implant to be the
answer to many problems that dogged the
medical profession.
Manna from heaven.
Add to this the conspicuous studies that
metallurgy has made & the gains that will be
seen the even better & varied application of
implants.

THANK YOU
Leader in continuing dental education


Implants in orthodontics 1 /certified fixed orthodontic courses by Indian dental academy

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