Clinical Guidelines for Dental Implant Treatment

A MANUAL OF THE SYSTEM osd 2001, Vol 12

Clinical Guidelines for Dental Implant Treatment Kari Luotio

Published as vol. 12 in Oral Surgery Diagnosis 2001 Kuopio FINLA ND Printed: Oy Kotkan Kirjapaino Kirjapaino Ab 2001 ISBN: 951-98037-1-8 Design: muotoari tmi

A MANUAL OF THE SYSTEM Clinical Guidel Clinical Guidelines ines for f or Dental Dent al Implant Trea reatment tment Edited by Kari Luotio

OSFIX International Ltd. Oy P.O. BOX 14 FIN-47201 Elimäki tel. + 358 5 779 7700 fax + 358 5 7797763 www.osx.

FOREWORD: Osx - from philosophy to system The main task of dental implantology is occlusal rehabilitation. We should call the end product a prosthesis, whether it is removable or not. As described, a prosthesis is a substitute for an organ or its function. At best, a patient should be able to forget that they using a prothesis and its existence should in itself be satisfying to them. If we can full these criteria, we have given the patient a gif t, a gift which is one of the mos t important they will ever receive. The eld of dental implantology increased rapidly until the beginning of the last decade. This is explained not only by the increasing level of dentists’ knowledge and skills, but also by the various national social security systems in Central Europe and some Scandinavian countries. Today, these systems are less effective as a result of economic depression. This has forced the development of reasonable, simplied and rational dental implant systems such as the Osx system. It is possible to describe dental implantology as controlled risk-taking, based on skilled surgery in the jawbone, modern titanium fabrication and precision dental laboratory manufacturing. This involves three obligatory conditions for the implantologist: 1. A knowledge of anatomy; 2. the ability to handle tissues such as the mucous membrane, muscles, nerves, veins, bones, extra oral tissues, and even sinuses; and 3. the ability to assemble pref abricated titanium parts and hand-made dental laboratory products. If any of these claims are not fullled, the risk-taking is no longer controlled. Anatomical hand books were written a long time ago, therefore the idea of this book is not to teach surgical anatomy. However, repetitio est mater studiorum. It is not a waste of time to consider applied implantological anatomy, because a small misalignment of an implant may result in tremendous technical problems between the bone surface and occlusion becoming apparent. It is impossible to overstate the importance of the advice of experienced implantologists and the enormous knowledge which is available in other implantological books. It may be that surgeons are born, i.e. surgical capability is mainly inherent, not the result of academic education. If the implantologist has “good hands” the bone tissue also “feels good”. Some details in the Osx system may be at odds with general implantological faith and might contradict accepted “facts”. However, when the results are of a top-level European standard, it is a time to reconsider. The philosophy of Osx is 10 years old, today Osx is a system for which more and more references are available - scientic and clinical. Risto M.Kotilainen DDS, PhD Professor (OMF-Surgery) University of Kuopio, Finland

Professor Kotilainen has expressed his view that today, some implantological truths might be collapsing as a result of technical advances. One of these dogmas is the use of gold alloys in prosthetic frameworks, another is the need for titanium angulated abutments and the third is the as-machined titanium surface of the implant. The reality of competition between implant companies has broken down the last; almost every company uses rough surfaced, i.e. sandblasted, acid-etched or plasma-sprayed implants today today.. The second dogma is now falling down because more and more companies are offering pr osthetic components which are an integrated part of the cast work and are in direct contact with the implants. Moreover, the need for angulated parts may be avoided with skilful working. The last dogma still stands. However, if the implantologist does not wish to face that conict, it is always possible to use precious metal, i.e. gold prefabricated cast-on components, in the Osx system as well. Author

INTRODUCTION OF THE AUTHORS: AUT HORS: List of authors in alphabetical order: Ms. Hanhela, Marika: MSc - Editor, Part V Ms. Hiedanpää, Heini: Artist - Drawings in Part I and III Mr. Kotilainen, Risto: DDS, PhD, Prof. - Scientic review Mr.. Lappi, Timo: Dent. Tech., Mr Tech., Production Manager - Part II, photographs in Part I Mr. Luotio, Kari: DDS, PhD, Consultant Surgeon - Parts I and V, Senior Editor Ms. Petrelius, Ulla: DDS - Operations in the clinical test Ms. Poussa, Tuija: Tuija: MSc - St atistical consultations Mr.. Ryhänen, Janne: DDS - Operations in the clinical test Mr Mr. Smith, David: - Language editing Ms. Stenberg, Tuula: MSc, PhD - Coating study Ms. Turunen, Turunen, Jaana: Dental Hygienist. - Part III and follow-up study Mr. Vesanen, Hannu: DDS - Animal study Ms. Vuori, Tiina: MSc - Linguistic consultation

The author would like to thank the above mentioned for their assistance in the project to develop a new implant system. In addition, the author extends his gratitude to everyone else who has participated in the process: per forming their graduation work for the company, colleagues giving professional advice and nancial support to the project.

ABBREVIATIONS: Ag

Silver

Au

Gold

B-Hb

Blood haemoglobin

B-leuc

Bloob leucocytes

B-sed

Blood sedimentation rate

Cl

Chloride

Cr

Chromium

Co

Cobolt

DLC

Diamond Like Coating

fB-glu

Blood glucose during fast

HCl

Saltic acid

Nm

Newton meter

RAD

Unit of radiation. More details e.g: http:// bartleby.com/64/ C004/037.html

Ti

Titanium

TiN

Titanium nitrate

ESSENTIAL TERMS

Support legs i.e. integral abutments

Totally xed (acrylic) denture

CoCr / Au framework with integral abutments (custom made)

Prosthetic srews (prefabricated)

Implants (prefabricated)

Support legs i.e. integral abutments

Implants

Acrylic teeth (prefabricated) “gingival acrylic” i. e. red prosthodontic acrylic connecting teeth and framework (custom made).

Bar construction

Support legs i.e. integral

(custom made)

abutments

Implants

MAIN MENU: FOREWORD INTRODUCTION OF THE AUTHORS ABBREVIATIONS ESSENTIAL TERMS PART I:

Clinical........................................................... 9

PART II:

Laboratory................................................... 85

PART III: Hygiene ..................................................... 101 PART IV: Sedation .................................................... 115 PART V:

Studies ..................................................... 145

KEYWORDS ............................................................. 203

PA R T

I

CLINICAL

Clinical guidelines for surgery and prosthodontics

Page - 10

PART I CONTENTS: 1. INTRODUCTION 1.1 The Osx Dental Implant System - A brief review of literature and presentation of the products.......15 1.1.1 Surgery .....................................................15 1.1.2 The prosthetic structure ............................16 1.1.3 Cobalt chrome as frame material .................16 1.1.4 Expected success rate ...............................16 1.1.5 Special techniques in surgery ......................17 1.1.6 Presentation of the product ........................18 1.2 The structure of Osx and Biosx implants.........19 1.2.1 Osx .........................................................19 1.2.2 BiOsx.......................................................20 1.3 The prosthetic superstructure..........................23 1.3.1 Totally osteointegrated prostheses ............. 23 1.3.2 Prostheses supported with osteointegration 24 1.4 Patient satisfaction .........................................24 1.5 Main solutions .................................................25 1.6 Components ....................................................26 2. OSTEOINTEGRATION AND TITANIUM IMPLANTS.........30 2.1 Osteointegration .............................................30 2.2 Rejection of foreign materials............................33 2.3 Bone tissue .....................................................34 2.4 Healing of bone after a trauma..........................35 2.5 Epithelial attachment .......................................35 2.6 Implants..........................................................35 2.6.1 Subdivision.................................................35 2.6.2 The osteointegrating titanium implants used 35 3. PLANNING THE TREATMENT 3.1 Indications.......................................................36 3.2 Contraindications.............................................36 3.3 Diagnosis and examinations needed ...................38

Page - 12

3.4 Placing the implants.........................................41 3.4.1 Maxilla .......................................................41 3.4.2 Mandible ....................................................42 3.4.3 The mutual placing of implants .....................46 3.4.4 The superstructure ....................................47 3.4.5 Partial prostheses or short bridges .............48 3.4.6 Grading of bone for design construction .......48 4. THE PROCEDURES ................................................50 4.1 Surgery - primary operations ............................50 4.1.1 Aseptic and other preparations ...................50 4.1.2 Medication.................................................54 4.1.3 The operation .............................................54 4.1.4 Postoperative treatment of the patient........59 4.2 Secondary operations.......................................59 4.2.1 Impression phase .......................................59 4.2.2 Mounting the prosthetics ...........................61 4.2.3 Service of xed prosthesis ..........................62 5. EXAMPLES 5.1 Biosx ............................................................63 5.2 Standard xing bar ..........................................69 5.3 Totally xed prosthesis ....................................73 5.4 Combination ...................................................76 5.5 Aesthetic problems .........................................79 6. FAILURES ..............................................................81 6.1 Loss of Implants ..............................................81 6.2 Mistakes in structural design ...........................81 6.3 Mistakes in fabrication .....................................81 6.4 Patient related factors.....................................81

Page - 14

1.

INTRODUCTION

1.1

The Osx Dental Implant System - A brief review of literature and presentation of the products

YOU ARE IN:

1.1.1 Surgery A factor important to the success of

primary stability during the procedure

the implant is the unstressed recovery

could be found.

allowed by two-phase surgery. The

PART I: Clinical 1.

INTRODUCTION

1.1

The Osx Dental Implant System - A brief review of literature and presentation of the products

1.2

The Structure of Osx and Biosx implants

1.3

The Prosthetic superstructure

1.4

Patient satisfaction

1.5

Main Solutions

1.6

Components

2.

OSTEOINTEGRATION AND TITANIUM IMPLANTS

3.

PLANNING THE TREATMENT

result of the primary recovery after

The Osx system allows the use of an

implantation is full osteointegration,

internally cooled drilling system during

in which the implant is joined, without

primary surgery. The relevance of

any connective tissue layer, directly to

internal cooling has been researched

the bone. It should also be mentioned

by Haider et al. (1993) in a histological

in this context that the implant is then

study based on the contact percentage

completely surrounded with compact

of new bone grown onto the surface

bone which will remain around the

of the implant. In this work, external

implant when it is subject to strain

cooling showed better results in the

at a later stage. This phenomenon

initial phase of the drilling when the

has been studied by Kraut et al.

bit forces were concentrated on the

(1991) by the use of tension tests.

surface bone, but the advantages of

They discovered that the mechanical

internal cooling are apparent when

immobility of the implant improved

the drill moves deeper into compact

4.

THE PROCEDURES

continuously, starting 2 weeks after

bone. This phenomenon has also

5.

EXAMPLES

surgery and continuing until 24 weeks.

been thermographically studied, even

This nding clearly supports a half-year

though such tests do not necessarily

6.

FAILURES

recovery period before subjecting the

hold any implications for the clinical

implant to strain. Their research also

importance of these phenomena. The

indicated that the extraction forces

test

are considerably greater from the

signicant differences when no cooling

mandible than from the maxilla. As

was used (Watanabe et al. 1992).

results

showed

the

most

PART II: Laboratory PART III: Hygiene PART IV: Sedation PART V: Studies

a contrast, no correlation with the References at the end of Part I

Page - 15

1.1.2 The prosthetic structure The

importance

of

prosthetic

25 mm distance apart. Implant losses

constructions for the success of

caused by a poor structure of the

implants, mentioned above, has been

prosthesis were rare, and whenever an

studied by Hertel and Kalk (1993) using

implant was lost, a prevalent factor

a group of 81 patients: the effect

was the patient’s ability and will to

of the distance between implants was

care for his oral hygiene. There are

compared with radiologically observed

also some infection factors, such as

loss of bone. The most signicant

Kellett and Smith’s (1991) nding that

loss was found amongst overdenture

the loss of an implant may follow a

patients with a supporting bar xed on

specic infection with a ecosystem

two implants in a toothless mandible.

and bacterial ora which is often

The conclusion was reached that the

seen in connection with periodontal

optimal placing of implants is ca.

illnesses.

1.1.3 Cobalt chrome as frame material It is general practice that an implant

removal of the cobalt chrome alloy

frame is made of gold alloy but,

components from implant and dental

mainly for reasons of economy, cobalt

structures. According to some studies,

chrome alloy is a promising material

cobalt chrome alloy components may

for the same purpose. Cobalt chrome

dissolve in oral conditions (Stenberg

alloy is a material commonly used

1982,

for other dental prostheses and its

corrosion has been claimed to cause

properties are well-known by both

loss of bone around the implant

dentists and dental technicians. One

(Adell et al. 1981, Lemons 1988, Geis-

of the disadvantages of cobalt chrome

Gerstorfer et al. 1989). The clinical

alloy is its hardness, which makes

follow-up of implant prostheses does

the material difcult to handle in a

not, however, support this claim

dental laboratory. Eventual allergenic

(Hulterström and Nilsson 1994, Luotio

reactions to cobalt chrome should also

1997), but indicates that the loss of

be taken into consideration, although

bone is at a similar level as that for

they are extremely rare. All structures

gold-based structures (Albrektsson et

should be designed to enable the

al. 1986, Cox and Zarb 1987).

Moberg

1985).

Galvanous

1.1.4 Expected success rate

Page - 16

The success rates of implants have,

followed 2,023 implants placed into

over the years, become quite clearly

a total of 974 patients. All prosthetic

dened. Scientic follow-up studies

structures were represented from

on implants with a roughened surface

single tooth implants to full dentures

structure hold a reasonably good

completely tted to the bone, and full

promise for the success of the

prostheses supported with a bar. The

treatment. Fugatsotto et al. (1993)

cumulative success rate at the end of

the 5 year follow-up study was 93 % for

implantation process was good: of

the maxilla and 96 % for the mandible.

more than 1,000 implants, only 9

A study by Babbush and Shimura (1993)

were lost at secondary surgery due to

PART I: Clinical

followed 1,059 implants placed in a

inadequate integration. The remaining

1.

INTRODUCTION

total of 322 patients; the  nal success

28 implants were lost during the 5 year

rate in a 5 year follow-up was 96 %.

follow-up period. This study conrmed

1.1

A division of success rates between

the implantologically accepted fact

jaws gave a rate of 92 % for the

that the longer and wider the implant,

maxilla and 99 % for the mandible.

the better the result.

The Osx Dental Implant System A brief review of literature and presentation of the products

1.2


1.3


1.4


1.5

Main Solutions

1.6

Components

2.


YOU ARE IN:

Thus the primary success rate of the

1.1.5 Special techniques in surgery Special techniques in implantology are

with venal blood and corallic hydroxyl

described, to some extent, in the

apatite, it is placed around the implants

literature. The common factor in

and the sinus lift cavity (Luotio,

these techniques seems to be the

Petrelius 1994). All these methods

use

direct

remain highly experimental and very

ossication, and the potential of

little scientic material is available

hydroxyl apatite. Implants have also

thereon. Thus a general application

been used in immediate implantations

is not yet justied and, for the time

and expansions of the crista, in which

being, Osx implants should not be

missing bone areas are lled with

used in experimental surgery.

3.


with lms that enhance ossication

Similar conditions apply to the use of

4.

THE PROCEDURES

(Novaes and Novaes 1992, Ettinger et

some new cleansing methods such as

5.

EXAMPLES

al. 1993), as well as maxillary sinus

the air-abrasive equipment developed

transfer operations. In this process,

to cleanse transmucosal extensions

6.

FAILURES

a hole is carefully made in the bony

and infected implant surfaces. Even

wall of the sinus, without breaking the

though studies have shown that such

mucosa. The mucosa on the base of

equipment does not, as such, impair

the sinus is lifted with a bent periosteal

the surface of the implant or make it

elevator from the future implantation

more attractive to bacteria (Barnes et

site, which enables direct visibility

al. 1991), at present the use of these

when drilling the holes through the

systems involves rather high risks and

base of the sinus. The bony drilling

possibilities for complications (Van de

waste is collected and nally, together

Velde et al. 1991).

of

various

lms

to

porous hydroxyl apatite and covered


Page - 17

1.1.6 Presentation of the product The Osx implant is a cylindrical implant

a bridge implant that enables the

with an apical screw portion for

construction

improved primary stability. The implant

structures to support the prosthesis.

has an internal hexagonal structure for

The main differences between the

tightening during surgery. The implant

Osx

is made of grade 2 pure titanium and

implants is the simplicity of the

the implant surface is mechanically

structure, the low component count

coarsened. The upper section of the

and the low price of the product.

of

implant

dolder-type

and

other

bar

existing

implant is polished. The length of the implants are 11.0 and 13.5 mm

The base of the Osx implant is

and the outer diameter 3.75 mm. The

formed by the actual implant cylinder,

Osx implant is primarily designed for

which is tted to the jawbone. This

use in bar retained over-dentures in

is covered during the rst operation

the lower jaw in totally edentulous

with a primary screw. In a subsequent

patients, but many other indications

operation, the screw is removed from

are valid, as described later.

the implant cylinder and replaced by an impression post, which is tted into

Osx implants are products made

place with occlusal screws included

by Osx International Ltd Oy. They

in the set. The impression posts are

are friction fastened, mechanically

then delivered to a dental laboratory

roughened implants in which primary

where they are cast into part of the

stability has been increased with a

superstructure.

threaded tip. The Osx implant is

a minimun of three OSFIX implants are needed for each frame structure

Page - 18

1.2

YOU ARE IN:


PART I: Clinical

1.2.1 Osx The basic element of the Osx implant

bridge may not be built on one or

is a titanium implant cylinder equipped

two implants, as rotational movement

with an apical screw, which is xed in

of

the alveolar bone. The cover screw is

contraindication in this system. For

screwed onto the cylinder in the

single crowns and short bridges, the

rst

subsequent

Biosx implant should be used, as it is

impression procedure, the cover screw

a single tooth implant supplied with a

is removed and a bridge construction

rotation check or hexagon.

operation.

In

a

the

bridge

is

an

Osx. The prosthetic structure of Osx differs from other systems in that the Osx implant is the rst dental implant system which has been designed to use cobalt chrome frameworks.

t The use of various alloys n a t is possible: The system r o contains burn-out p m components for CoCr and i cast-on components for gold and metal ceramics. Machined titanium

A minimum of three Osx implants

components are also

are needed for each frame structure.

available to order.

It is important to understand that a

INTRODUCTION

1.1


1.2


1.3


1.4


1.5

Main Solutions

1.6

Components

2.


3.


4.

THE PROCEDURES

5.

EXAMPLES

6.

FAILURES

absolute

is made and tted in place with the prosthetic screws supplied by

1.

PART II: Laboratory PART III: Hygiene The prosthetic screw not only secures but also aligns the components.

Only three parts: Implant, screw and prothesis

PART IV: Sedation PART V: Studies

Page - 19

1.2.2 BiOsx

Page - 20

BiOsx is a titanium implant for single

development in prosthetics is the fact

teeth and short bridges (two implants).

that the implant structure can be

This system is compatible with the Osx

completely dismounted. If the surface

surgical system, although it offers a

structure has to be renewed, e.g. for

prosthetic solution of its own. The

a front tooth implant made during

basic principles of the implant are very

the growing period, it is possible

similar to those of Osx, it is a sand-

to dismantle the whole implant and

blasted implant with a mechanically

replace the crown with a larger one.

polished collar to provide good contact

Similarly, it is possible to repair severe

with the connective tissue, and a

cases of loosening screws in single

built-in rotation check, the hexagon,

tooth implants without loss of the

or an internal “bolt head”. A major

prosthetic structure.

t BiOsx is based on n a t cast-on components i. e. r o metal ceramic crowns. p m Machined titanium i components are available

Prosthetic variations of BiOsx: - Cementation on custom made abutment

YOU ARE IN: PART I: Clinical 1.

INTRODUCTION

1.1


1.2


1.3


1.4


1.5

Main Solutions

1.6

Components

2.


3.


4.

THE PROCEDURES

5.

EXAMPLES

6.

FAILURES

- Screw retained crown

to order.


Page - 21

Only three parts: Implant, crown and screw

Page - 22

1.3

YOU ARE IN:


PART I: Clinical

1.3.1 Totally osteointegrated prostheses

1.

INTRODUCTION

1.1


1.2


1.3


1.4


acrylic replaces the resorbed alveolar

1.5

Main Solutions

ridge and gums, tted with ordinary

1.6

Components

2.


3.


4.

THE PROCEDURES

5.

EXAMPLES

6.

FAILURES

In

the

Osx

system,

these

are

the occlusion forces fully correspond

constructed on a maximum of ve or

to those of natural teeth, whereas

six implants in the bone, tted with a

the occlusion forces of an ordinary

metal framed, acrylated full denture:

prosthesis are only 1/4 - 1/5 those of

a chrome cobalt frame full denture

natural teeth. Totally osteointegrated

with acrylic teeth is tted on the implants. In some cases, the chrome cobalt frame also forms the lingual or palatal surface of the bridgework, but often it forms only the base that connects the implants. On or around this chrome cobalt structure, red

plastic prostheses. A hole for each implant passes through the whole structure. The prosthesis is held in place with six screws. When the prosthesis is nally taken into use, the screw openings are covered with composite lling material. This method enables full stability and complete occlusion forces for the

PART II: Laboratory

prosthesis, although problems such as air leaks may occur, especially in

PART III: Hygiene

the maxilla between the palate and the prosthesis, or aesthetic problems

PART IV: Sedation

due to transmucosal metal extensions

PART V: Studies

in cases of incomplete lip-closure. Visual or phonetic compromises that complicate cleaning are often needed in the maxilla.

prostheses

may

also

be

partial

prostheses tted on three, four or Due to anatomic limitations, the

even ve implants in an edentulous

implants often need to be focused

rear or middle area. The structure

anteriorically. A fully osteointegrated

of these either corresponds to the

prosthesis with a metal frame structure

previous prosthesis, or is made of

can take a cantilever in the maxilla up

composite and metal frame. Ceramics

to 10 mm, and in the mandible up to

are being tested in the Osx system

20 mm. With this kind of prosthesis,

but are not yet in clinical use.

Page - 23

1.3.2 Prostheses supported with osteointegration These are not permanently xed to the implants, but may be removed by the patient. A typical prosthesis would be an overdenture built on three or four implants in the mandible, fastened to the Osx bar in a manner that allows most of the occlusal stress to be transferred to the mucous membrane due to a seesaw movement.

1.4


The biggest advantage is felt by

dramatic. For the patient, important

patients whose lower prosthesis is

functional advantages are increased

supported

which

ease of speech and its clarity, as well

increases the stability of the prosthesis

as a more positive facial expression,

and reduces feelings of pain. Similar

and what is seemingly very important

changes also occur in the maxilla,

to the patients, the ability to laugh

but in the case of the mandible,

safely (see PART V).

with

implants,

the changes could be described as

Page - 24

1.5

Main Solutions

YOU ARE IN: PART I: Clinical

Removable Osx denture

1.

INTRODUCTION

1.1


1.2


1.3


1.4


1.5

Main Solutions

1.6

Components

2.


3.


4.

THE PROCEDURES

5.

EXAMPLES

6.

FAILURES

PART II: Laboratory PART III: Hygiene Fixed Osx denture

PART IV: Sedation PART V: Studies

Partial Osx denture and BiOsx crown

Page - 25

1.6

Components

OSFIX Components

OSFIX implants: • ø 3.75 mm • Lengths: 11 mm and 13.5 mm OSFIX Laboratory components: • OSFIX Prosthetic screw, • OSFIX Implant analogue OSFIX Cover screws:

• OSFIX TM Extension burn-out

• Lengths: 0.5 mm and 1.5 mm

• OSFIX TM Extension cast-on

OSFIX Healing posts: • Lengths: 3 mm, 4.5 mm, 6 mm and 7.5 mm

OSFIX adaptation drills • ø 2.8 mm • ø 2.6 mm

OSFIX Impression posts: • wide, narrow, long

Page - 26

scale 3:2


BiOsx Components

1.

INTRODUCTION

1.1


1.2


1.3


BiOsx Implant analogues:

1.4


• ø 4.2 mm and 5.0 mm

1.5

Main Solutions

1.6

Components

2.


3.


4.

THE PROCEDURES

5.

EXAMPLES

6.

FAILURES

BiOsx Prosthetic screw

BiOsx implants: • ø 4.2 mm and 5.0 mm • Lengths: 11 mm, 13.5 mm and 16 mm

PART II: Laboratory BiOsx Prosthetic kit Hexagon • ø 4.2 mm and 5.0 mm

PART III: Hygiene PART IV: Sedation

BiOsx healing posts:

PART V: Studies

• ø 4.2 mm and 5.0 mm • Lengths: 3.4 mm and 4.5 mm

BiOsx Copyposts: scale 3:2

• ø 4.2 mm and 5.0 mm

Page - 27

OSFIX and BiOsx Drills

PILOT-DRILL

STEP-DRILL L2

STEP-DRILL L6

STEP-DRILL S2

STEP-DRILL S6

twist drill 3.7 mm

twist drill 3.3 mm

counter-sink 4.2 mm

counter-sink 5.0 mm

scale 3:2

Page - 28

OSFIX and BiOsx Instruments scale 5:7


INTRODUCTION

1.1


1.2


1.3


1.4


1.5

Main Solutions

1.6

Components

2.


3.


4.

THE PROCEDURES

5.

EXAMPLES

6.

FAILURES

PART II: Laboratory Mallet

Tapping pin

Ratchet

PART III: Hygiene PART IV: Sedation PART V: Studies

BiOsx Connector

OSFIX Connector

Drill extension

Screwdrivers

Page - 29

2.


2.1

Osteointegration

Osteointegration is dened as the

beginning in the 70s. During the 1980s,

direct contact of the implant with

many scientic symposia were held on

the bone, without any soft-tissue layer

implantology, and the rst temporary

between. Titanium has been proven

approvals for titanium implants were

to be the best material for implants,

granted by the ADA. Implants began

as its osteointegration with stands a

to be placed in patients in meaningful

force of over 100 kg. Even with this

quantities at the beginning of the 90s,

force, the implant is not loosened, but

at which time the development of the

is broken off the bone.

Osx implant also began. The Osx implant acquired sales permission for

Page - 30

Early research and actual development

the whole European Union in 1998,

work in osteointegrated implantology

when the quality assurance system in

was made at the turn of the 60s

production and clinical studies were

and 70s, with commercial production

nalised.

YOU ARE IN:

Key factors in osteointegration 1. Grade 2 titanium of over 99 % purity.

Celsius, and the rotation speed of the drill must be below 2,000 rpm.

2. An oxide layer forms on the

5. Two-phase surgery that allows

titanium surface to which the

osteointegration without

glyco-protein layer will attach and

disturbance; the implant

later calcify.

structures will be subjected to

3. The shape of the implant distributes the occlusion stress evenly to the bone. A triple surface increase has been created in the Osx implant: the apical screw, the micro screw of the stem and the sand blasting on the surface of the implant multiply its surface area. 4. The use of the correct (internal)

strain only after the proper osteointegration period of 3-6

PART I: Clinical 1.

INTRODUCTION

2.


2.1

Osteointegration

2.2

Rejection of foreign materials

2.3

Bone tissue

2.4

Healing of bone after a trauma

2.5

Epithelial attachment

2.6

Implants

3.


4.

THE PROCEDURES

5.

EXAMPLES

6.

FAILURES

months. 6. High asepsis in procedures. 7. The formation of a proper epithelial integration in the second phase

cooling during preparation. The temperature in the preparation area must not exceed 40 degrees

PART II: Laboratory PART III: Hygiene PART IV: Sedation Osteointegration

of

sandblasted

PART V: Studies

implants in the jaw bone of a dog (beagle).

Page - 31

Criteria for successful osteointegration 1. The implant is fully immobile in the secondary operation 2. The x-rays show no radiolucence around the implant 3. No marginal loss of bone can be observed

4. No permanent damage can be found in the nerves; neither pain nor infection 5. Success rate at a 10 year follow-up should be over 90 % (Osx 100 % in 4 years)

Histological sample shows proper osteointegration in the animal test.

Page - 32

2.2

YOU ARE IN:


The antigen-antibody reaction will

Connective tissue organisation or

reveal any alien proteins found in the

encapsulation means that foreign

living system. Corroding metal ions

material

will form complexes with the system’s

surrounded with connective tissue. The

own proteins that are recognised

thickness of the capsule will depend on

as

titanium

the material causing the reaction. With

implants must be kept clear of any

PART I: Clinical 1.

INTRODUCTION

2.


the exception of titanium, practically

2.1

Osteointegration

saliva or foreign metal contamination.

all materials are encapsulated in the

2.2

The package efciently protects the

system. The movement of foreign


Osx implant until the very moment

material is known to enhance the

2.3

Bone tissue

it is placed in the bone, whilst the

capsulation around it, therefore the

cylindrical

primary xation of the implant is

2.4


2.5


2.6

Implants

3.


4.

THE PROCEDURES

antigenes.

protection

Therefore,

primary

insertion

against

gives

contamination

in

the

system

will

be

extremely important.

during the procedure.

2.3 Bone

Bone tissue is

structurally

divided

into

dense bone is the biologically active

compact and spongious bone, or

cell layer of the bone, made up of

dense and cancellous bone; chemically

osteoblasts and osteoclasts. Their task

into organic and inorganic bone, each

is to form new bone in the event of

5.

EXAMPLES

of which amount to about 40 % of

injuries. The outermost layer is the

6.

FAILURES

the bone. The organic part consists

periosteum which is attached to the

of collagen, glycosaminoglycans and

bone by ligaments.

PART II: Laboratory

osteonectin. The inorganic part is almost entirely made up of hydroxyl

The function of the bone is to act

apatite.

both as a supportive structure

and

as a store for calcium. The exchange The inside of the bone tissue is

of calcium between blood and bone

cancellous bone formed by thin bony

tissue is many tenfold compared to

lamellae. This trabecular architecture

the normal calcium intake from food.

makes the structure of the bone lighter

Most of the calcium stored in the

whilst maintaining its strength. This

skeletal structure is rmly bound in

part of the bone contains the vascular

the bone and balanced hormonally by

system while the dense bone carries

parathormone and calcitonin.


no blood vessels. On the surface of the

Page - 33

2.4


Primary healing: The bone heals after

thus reaching the nal stage of this

a trauma when the fracture is clean

healing process, when a pseudarthrosis

and full xation is obtained. Blood

or false joint is formed in the bone.

coagulates in the area with extensive phagocytic activity during the rst few

Healing

days. Thereafter, a procallus is formed

procedure: Depending on the initial

and great numbers of broblasts can

situation, any of the previous healing

be observed microscopically. When the

processes

connective tissue has become dense it

implantation procedure. If secondary

is referred to as callus. This is where the

healing takes place, the implant is nally

rst osteoblasts appear. Following this,

surrounded with pseudoperiodontal

maturation occurs or the osteogenic

ligament

bres in the callus begin to calcify.

pseudarthrosis. The nal stage is called

Compact bone is formed initially, and

brointegration. This type of healing

later it is organised into compact and

can

spongy bone. Thus, the normal primary

implantation, but if the implant is

healing of the bone has taken place.

strained, fast resorption of bone

in

may

implantation

appear

after

corresponding

never

occurs,

the

produce

followed

by

the

to

long-lasting

infectious

Secondary healing: Secondary healing

reactions, leading to the loss of the

is found in bone in cases of large,

implant.

impure and comminuted fractures. No

Page - 34

stability is reached and the situation

The result of primary healing after

is often complicated by infection.

implantation is full osteointegration,

Granulation

extensive

in which the implant is joined directly to

infection forms in the area. This is

the bone without any connective tissue

followed by delayed healing and a

layer. It may be noted that the implant

vicious circle in which the infected

is fully surrounded by compact bone

granulation tissue does not contribute

which remains around the implant

to the creation of stability. Finally,

after the well-timed introduction of

brous cartilage is formed in the area,

loading.

tissue

and

2.5

YOU ARE IN:


In a natural tooth, the junctional

to stop infection factors from reaching

epithelium is long and reaches right

into the dentoalveolar junction.

through the gingival enamel, up to

PART I: Clinical 1.

INTRODUCTION

2.


the enamel dentine. The epithelium

A normal junctional epithelium is

ends its migration when it reaches

formed against the mucosal piece of

the brous attachment structure of

the implant. In successful implantation,

the tooth. The junctional epithelium

when oral hygiene is good, a healthy

2.1

Osteointegration

shows continuous migration of cells

connective tissue layer is, almost

2.2

from the germinal layer up along the

without exception, found under the


tooth surface, the epithelium cells

epithelium, and thereunder begins

2.3

Bone tissue

nally scale off from the gingival

unresorbed bone that is directly

papilla. The purpose of this migration is

connected to the implant.

2.4


2.5


2.6

Implants

3.


4.

THE PROCEDURES

2.6

Implants

2.6.1 Subdivision Implants

can

be

divided

into

chrome cobalt screw at the beginning

endodontal, subdermal, subperiosteal

of the 60s. Acrylic was also tried as

and endosteal implants, of which

a xture material in those days, and

only the last mentioned will now be

carbon-glass in the 70s. In its day, the

5.

EXAMPLES

examined.

popular Linkov’s plate was a success,

6.

FAILURES

but reached only a 50 % success r ate in Endosteal dental implants are further

long-term follow-up. The rst implant

divided into screw, plate and cylinder

material with a 90 % success rate was

types. The materials used have been

the ceramic developed in the 80s;

cobalt chrome, carbon, ceramics and

aluminium oxide. The 90 % limit can,

titanium. The rst screw types were

signicantly, be surpassed only with

developed as early as the 1940s and the

titanium implants.


2.6.2 The osteointegrating titanium implants used There are several titanium implant

simply prepared models, such as Osx.

systems available in Europe, from

It must be remembered, though, that

various manufacturers. Almost all

the implant adheres to the bone with

implant types based on titanium reach

its surface. Therefore the prognosis

well over 90 % success rate in a

for short and narrow implants is much

10 year follow-up. Cavity or thread

poorer than that for long and wide.

preparations are extremely demanding

Regardless of the make of implant,

procedures and this possibly accounts

failures occur mainly with implants

for a lower success rate than with more

shorter than 10 mm.

Page - 35

3.


3.1

Indications

INDICATIONS FOR IMPLANTATION

OSFIX

In addition to the above mentioned indications, there are a few more grounds for implant treatment. These

1. An edentulous patient

alone or combined with other reasons, 2. A partly edentulous patient with a gap of at least three teeth

actual indications, may be the decisive factors for the implant treatment. The patient may have such a weak bone

INDICATIONS FOR IMPLANTATION

BIOSFIX

1. Lack of one tooth 2. Lack of two adjacent teeth 3. Other Indicators:

structure that the use of ordinary partial prostheses is extremely difcult. Poor muscle co-ordination and a hypersensitive

mucosa

are

other

common reasons for the failure of ordinary

loose

prostheses.

A

hypersensitive swallowing reex usually t BiOsx permits every n a t kind of implantological r o indications if custom p m made angulated i abutments and cemented bridges are used.

prevents the patient from using an ordinary plate prosthesis in the maxilla. For some patients, even a partial lack of teeth may be so distressing that ordinary loose prostheses are, again, out of the question. It is also best these days to replace the loss of one tooth with an implant, as bridge constructions seem to be approaching professional malpractice.

3.2

Contraindications

1. Radiotherapy of over 5,000 rad i.e. radiation treatment with primary

which a minimum of one year’s

scale on the jaw area (see

recovery after extraction is

hyperbaric oxygen therapy)

needed before implantation

2. Psychoses and dysmorphophobia

5. Immediate extraction. A minimum

or fear of changes in the

of 3 months’ recovery period

appearance

before implantation.

3. Leukaemia, haemophilia,

Page - 36

4. Periodontitis and infections, for

6. Tumours, which rst have to be

thrombocytopenia and diseases in

removed and the bone left to heal

ASA groups 3-4

until normal.

As a relative contraindication, it is of ten

in charge of the radiotherapy. The

mentioned that addiction to drugs,

same applies to high blood pressure

alcohol or cigarettes can prevent the

and diabetes. Neither of these systemic

PART I: Clinical

patient from following the restrictions

diseases is an actual contraindication,

1.

INTRODUCTION

during the rst few days. Smoking

if they are kept under control with

is considered a risk factor in the

medication.

2.

prognosis as it is.

nevertheless needed whenever the


3.


3.1

Indications

3.2

Contraindications

3.3

Diagnosis and examinations needed

3.4

Placing the implants

4.

THE PROCEDURES

5.

EXAMPLES

6.

FAILURES

Consultation

is

patient has a fairly serious systemic A radiation dose below 4,000 rad or the

disease (ASA 3-4).

amount of secondary radiation should always be discussed with the physician

BIOSFIX: For single tooth replacement

YOU ARE IN:

PART II: Laboratory PART III: Hygiene PART IV: Sedation

OSFIX:

PART V: Studies

At least three implants in each framework Hyperbaric oxygen therapy Radiation creates a contraindication for implantation as the preconditions for osteointegration and inammatory respo nse are weakened due to decreased secretion of saliva and cellular changes in the tissue. A real solution for an irradiated area is the use of hyperbaric oxygen treatment in implantation. The ther apy is begun before the implantation as a series of 20 treatments, and is continued af ter the implantation with a series of 10 treatments. Each treatment consists o f a 1.5 hours therapy with 2.4 atmospheric pressure oxygen. Increasing the number of treatments has no proven benet. The advantage of the treatment is the increase in oxygen content in the tissue of hypoxic bone, and the following restoration of the vascular system in the radiated tissue. Thus the injury reparatio n mechanisms are normalised in the tissu e. For the success of the implantation, the advantages of hyperbaric oxygen treatment are obvious, as the implants would otherwise mostly be los t. After hyperbaric treatment, the success rate is increased to that of ordinary implantations. The treatment can be performed only in certain central hospitals.

Page - 37

3.3


Implantological diagnosis is based on

The assessment of the patient for

medical and dental history, and a

operation

clinical examination of the patient.

classifying the patient into one of

These are compiled into a written

the following groups (a modied ASA

description or summary of the case,

classication):

is

primarily

made

by

supplemented by a treatment plan. The size, number and placement of

1. Healthy patient

xtures is described, as well as the structure planned for the prosthesis.

2. Patient has a general disease which is kept under control with medication

The medical history consists of a careful record and the results of

3. Patient has a general disease (note

laboratory tests, if they have been

also if patient has reached an advanced

considered

age) which causes problems in daily

necessary.

common

laboratory

haemoglobin, leukocyte

most

tests

are

sedimentation

rate,

count

differential

The

and,

count,

coagulation

possibly,

4. Patient has a general disease with

thrombocytes,

a risk of serious attack or death as a

factors

or

TT,

blood-glucose level during fast and possibly

calcium,

if

metabolic disturbances with

calcium

are

suspected. The routine tests

include

sedimentation

rate,

leucocytes

and

haemoglobin,

and

always level

(B-sed, fB-glu).

Page - 38

would

blood-glucose

during

B-leuc,

life despite medication

fasting

B-Hb,

result of strain.

The rst group always qualies for

Dental

history

includes

earlier

operation. For groups 2 and 3 it

procedures:

llings,

periodontics,

is recommended that some form

extractions,

surgery

or

of sedation be used during the

occlusal therapy.

possible


INTRODUCTION

2.


3.


3.1

Indications

the procedures. The treatment of

3.2

Contraindications

group 4 patients should be avoided

3.3


3.4


4.

THE PROCEDURES

5.

EXAMPLES

6.

FAILURES

procedures, and for groups 3 and 4 there also has to be a vascular

Clinical examination concentrates on

connection, the ability to monitor

obtaining a full oral status. Plaster

vital functions (preoperative EKG and

model analysis of the relation of jaws,

preoperative pulse oximeter) and a

anterior and lateral photograph of

professional

the patient’s face as well as intraoral

emergency

specialist,

such as an anaesthetist, present during

photograph might also be useful.

with implantological implications, or if treatment is chosen, it should take place in a unit corresponding to hospital conditions.


Page - 39

The most important examinations

maxilla,

are

radiological

radiographs are quite sufcient. On the

examinations or orthopantomog-

other hand, transversal tomograms

ram, which is always needed. A

are invaluable in the implantation

lateral skull radiograph will show

of the posterior of the mandible, as

the relation of jaws and is valuable

well as a fully edentulous maxilla.

when the prosthesis structure is

When placing single implants in the

being planned. When implanting in

premolar section of the maxilla, it

the anterior of an edentulous mandible

is important to dene the shape of

or the anterior of a partly edentulous

the sinus and this is best done with

nevertheless

the

tomography.

Page - 40

above

mentioned

3.4

YOU ARE IN:


PART I: Clinical

3.4.1 Maxilla Typical for the maxilla is a small

the area of premolars. At the edge

total amount of bone and high ratio

of premolars, the sinus already limits

of spongious bone. The placing of

the length of implants, while the

the implants is further restricted by

molar section can rarely be considered

maxillary sinuses, the nasal cavity and

without a sinus lift operation which

incisive canal as well as the millary joint

has not been studied with the Osx

i.e. palatal suture. The best site for

implant.

a long vertical implant is the canine tooth area between the nasal cavity

The optimal placing of Osx implants

and maxillary sinus. Besides these two

in the maxilla is as follows:

1.

INTRODUCTION

2.


3.


3.1

Indications

3.2

Contraindications

3.3


3.4


4.

THE PROCEDURES

5.

EXAMPLES

6.

FAILURES

implants, there is usually room for four other implants, one pair vertically

15-14 (inclined),

under the nasal cavity and another behind the long implants roughly in

13, 11, 21, 23, 24-25 (inclined)


Page - 41

3.4.2 Mandible The best area for implants in the

can be obtained when there is room

mandible is the anterior area between

between the mental foramina f oramina for: for:

the mental foramina, if this area contains ca. 10 mm of bone, it

Six 11 mm long Osx implants,

is sufcient for implantation. When placing the implants in the mandible,

Five or six 13.5 13.5 mm long Osx implants, impl ants,

it should be remembered that the

or

mandibular canal makes an anterior loop just before reaching the surface,

Four or ve 16 mm long implants

and therefore the implant cannot be

(BiOsx).

placed directly adjacent to the mental foramens. The molar area of the

The basic solution in the mandible for

mandible may be used for f or implantation

Osx implantation is, almost without

if there is ca. 11 mm of bone above

exception, excepti on, ve 13.5 13.5 mm long implants, implant s,

the mandibular canal.

of which the outermost pair is placed at the foramen mentale with the apical

The sharp crestal area of the mandible

head inclined towards the median line;

makes

implant

the middle implants in the median line

treatment more complicated, as it

of the mandible and one pair between

has to be excised when installing

the two others (thus forming a fan

the implant. It also has to be noted

shape):

the

planning

of

that the orthopantomograph is greatly enlarged

(horizontally

50-70

%,

44 (inclined),

vertically 10-30 %). The best result 43-42, 41-3 41-31, 1, 32-33, 34 (inclined)

Page - 42


INTRODUCTION

2.


3.


3.1

Indications

3.2

Contraindications

3.3


3.4


4.

THE PROCEDURES

5.

EXAMPLES

6.

FAILURES


Page - 43

In cases of bar constructions, 3 or 4

distal implants should be inclined to

implants are used. Three implants are

allow sufcient space for the riders of

valid in resorbed bone cases and four

the denture.

in non-resorbed cases. However the

Page - 44


INTRODUCTION

2.


3.


3.1

Indications

3.2

Contraindications

3.3


3.4


4.

THE PROCEDURES

5.

EXAMPLES

6.

FAILURES


Page - 45

3.4.3 The mutual placing of implants The placing of the implants should

also be noted that Osx implants are

allow enough bone to be left bet ween

always placed in a fan shape, avoiding

the implants. A rule of thumb would be

parallel implantation. The fan may be

to leave a minimum of one implant’s

divergent or convergent, but the space

width of bone: when 3.75 mm implants

needed by impression posts should be

are used, ca. 4 mm bone should be

borne in mind.

left between the implants. It should

Page - 46

YOU ARE IN:

3.4.4 The superstructure The superstructure i.e. prosthesis must

and to think of the torsional forces

be considered during the implantation

of occlusion on the structure i.e.

phase. This means making sure the

lever arms. A rule for cantilevers in

implants are not parallel, to ensure

the superstructure is, at a maximum,

the

the last implant’s length. It must be

maximum

security

for

the

superstructure.

PART I: Clinical 1.

INTRODUCTION

2.


3.


remembered, however, that the bone structure of the maxilla is weaker

The problems caused laterally by the

than that of the mandible. Therefore

occlusal relationship of the jaws should

cantilevers in the maxilla must be

3.1

Indications

also be taken into account. A good

smaller than the length of the last

3.2

Contraindications

method of predicting the restrictions

implant while in the mandible it may

in jaw relations is to draw the

be a little longer. In practice, the

3.3


placement of the implants and the

cantilevers may not exceed 20 mm in

prosthetic structure on a lateral x-ray,

the maxilla or 10 mm in the mandible.

3.4


4.

THE PROCEDURES

5.

EXAMPLES

6.

FAILURES

PART II: Laboratory t It is extremely important n a t that the future position r o of the prosthetic screws p m are considered, especially i in implantations on the


anterior maxilla: the axis of the drill should always remain on the oral side of the facet line of prosthetic tooth or teeth.

Page - 47

3.4.5 Partial prostheses or short bridges The xation of a partial prosthesis to

should be used in wide toothless areas

the bone is, almost without exception,

where implants are faced with torsion

based on three Osx implants in an

forces, such as in the frontal area.

edentulous area. There is always room

In the molar area, implants also face

for these when the width of the

rotational forces that tend to open

edentulous area exceeds 20-25 mm.

occlusal screws, especially where a joint

If the opening is narrower than 20

between the bridge and the implants

mm, two BiOsx implants are used.

does

In practice, four or more implants

movement.

not

fully

prevent

sideways

3.4.6 Grading of bone for design construction The outer compact layer of bone may

Totally xed prostheses cannot be

be thin or thick, whilst spongious

fabricated in a strongly resorbed

bone may be loose or dense. This

mandible, but overdentures supported

grading alone offers four variations.

by two, or preferably four, implants

The resorption in the bone may be

should be used. In such cases, the

slight, medium or strong. When this

fastening of the overdenture to the

factor is taken into account, we

implant uses the mesiostructure i.e.

face 12 different variations, each

the Osx bar. Dalbo-type fasteners

posing

implantation

should not be used, as they would

problem. Therefore, the quality of

place considerably greater occlusional

the bone should always be graded

and torsional forces on the implants

before implantation. The best bone

compared to bar structures. It is

for implantation is slightly resorbed,

extremely rare to nd a patient with

with a dense spongy bone. A poor

insufcient bone in the mandible for

one is a strongly resorbed bone with a

an overdenture solution. In the maxilla,

thin compact layer and a loose spongy

an implant supported overdenture is

bone.

not a good solution, as the thickness of

an

individual

the structures often severely disrupts speaking.

Page - 48


INTRODUCTION

2.


3.


3.1

Indications

3.2

Contraindications

3.3


3.4


4.

THE PROCEDURES

5.

EXAMPLES

6.

FAILURES

PART II: Laboratory PART III: Hygiene PART IV: Sedation PART V: Studies The lever arm of the constructio n should be kept in mind. Resorbtion of the bone always results in a higher lever arm, which increases the angulating or bending component of occlusal forces.

Page - 49

4.

THE PROCEDURES

Appointments required for a prosthesis xed to the jawbone • Examinations

• Impression

• Planning

• Fitting of the framework

• Placing the implants

• Placing of the prosthesis and postoperative radiograph

• Relining for the prosthesis (e.g. with a temporary soft material when needed) • Secondary operation after 3-6 months

• Annual recall, service and radiological follow-up of the prosthesis

• Placing of the healing posts.

4.1

• Control call and training in oral hygiene

Surgery - primary operations

4.1.1 Aseptic and other preparations Personnel: Before the start of the

and surgical gown. The implantation

implantation operation, all instruments

procedure practically always requires

must be sterilised. The elimination

another nurse or an non-sterile or

of the patient’s own ora must be

circulating assistant to open the

ensured. The easiest way to do this

implant cases and pass the sterile

is to make the patient wash his own

contents to the surgeon.

face with a Hibiscrub® (chlorhexidin) skin wash, and rinse his mouth with a

Room:

Corsodyl® (also chlorhexidin) solution.

suitability of an ordinary consulting

After this, and before any other

room for implant surgery, the following

preparations, the patient’s blood

points should be considered:

pressure is measured. Blood pressure should also be measured after the procedure, and results recorded (also

note the points mentioned on the patient’s eligibility for operation). Before draping, the nurse will carefully cleanse the skin with alcohol. The drapes should be large enough to ensure that no contamination is transferred

accidentally

from

the

considering

the

1. The microbiological purity of the air conditioning and ventilation system 2. How well the oor can be cleaned 3. Sufcient light that can be correctly directed under sterile conditions 4. Whether the suction system gets

surfaces of the operating theatre to

blocked when accumulated blood

the sterile area. The outt of the

begins to coagulate in the tubes

surgeon and the primary assistant includes bonnet, masks, sterile gloves

Page - 50

When

5. The drill and engine should be powerful enough, and the handpiece able to be sterilised


If the normal dental surgery is used for implant surgery, some reorganisation facilities (see text) and separate prosthetic corner are recommended.

1.

INTRODUCTION

2.


3.


4.

THE PROCEDURES

4.1

Surgery - primary operations

4.2

Secondary operations

5.

EXAMPLES

6.

FAILURES


Page - 51

Clinical Guidelines for Dental Implant Treatment

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