Surgical considerations in the edentulous patients

for implant installation

Dept. of OMFS, School of Dentistry

Chonnam National University
2007.4.7
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Considerations in Edentulous Patients

1. General health
2. Anatomical condition
- Jaw relation
- Interarch space
- Remaining bone (morphology, quality)
- Anatomical structures
- Soft tissue condition
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Considerations in Edentulous Patients

3. Biomechanics
4. Esthetics
5. Oral hygiene maintenance
6. Treatment period
7. Cost
8. Prosthetic plan
9. Surgical skill, etc

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General Health Condition

DM, hypertension, CV, pulmonary, liver, renal diseases, etc.

Medical consultation

Treatment plan
: Minimial pain, cost, treatment period
Simpler operation
Long-term successful, simpler implant prostheses

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Radiographic Examination
Panorama, Lateral cephalo, CT taking

Pathology

Anatomical structure
: Mx. Sinus, mandibular canal, etc.

Ridge shape or quality

Available bone height & width, etc.

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Diagnostic Cast

Jaw relation

Degree of bone resorption

Vertical dimension : space for implant prosthesis

Wax-up, surgical stent

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Surgical Stent & Temporary Prosthesis

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Anatomical conditions

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Resorption Pattern of Edentulous Jaws

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Jaw Relation

Cl II

Cl I

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Correction of Jaw Relation

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Correction of Jaw Relation

Distraction Osteogenesis

Wrong vector control

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Correction of Jaw Relation by DO

Post-op 2 yrs

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Correction of Jaw Relation

04.6.12.

06.9.7.

Post-op 2 yrs

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Interarch Space
Biomechnics
Esthetics
Funtions : mastication, phonation
Prosthetic plan

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Biomechanic Considerations

Crown/implant ratio
Cantilever

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Prosthetic Plan

Function
Biomechanics
General, local condition
Cost
Surgical skill, etc.
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Overdenture

Cantilever
Leverage
Attachment,
etc.

Arch shape

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Mental Foramen

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Overdenture

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Temporary implant

2 , 4
ball type & short head for overdenture
Temporary denture ( )
Temporary fixed bridge
Soft diet (about 6wks)

If osseointegration

- Temporary implant removal

by using Trephine bur
- Submerge after removal
of the head
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Temporary implant
Intraoperative photographs

: Both sinus elevation with iliac PMCB bone,

onlay block bone graft, & temporary implant installation

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Temporary implant
Temporary implant & overdenture

Preop

Postop +1mo
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Types of Bone Quality

- Lekholm & Zarb, 1985

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Physiologic Changes of Edentulous Jaws

Osteoporosis
Fatty marrow
Loose trabecula
#36

#36

#36

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Osseointegration
in Poor Bone Quality

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Table 1. Percentage of bone-implant contact ratio in cortical bone of tibia (%)

Control
RBM
HA
SLA

Mean

SD

Minimum

Maximum

16
10
8
6

75.9
87.1*
95.4**
86.0*

11.9
5.3
2.9
3.5

69.5
83.3
93.0
82.4

82.2
91.0
97.8
89.7

*; p<0.05, **; p<0.01, SD; standard deviation

Table 2. Percentage of bone-implant contact ratio in marrow space of tibia (%)

Control
RBM
HA
SLA

Mean

8
8
6
8

29.6
36.7
76.1**
45.1

**; p<0.01, SD; standard deviation

SD

Minimum

Maximum

5.4
10.3
15.0
15.0

25.1
28.0
60.4
32.5

34.1
45.3
91.8
57.6
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Implantation in Poor Bone Quality

Minimal drilling
Use of osteotome
Implants
: Wide & long diameter
Rough surface
Threaded, self-tapping implant
Number of implant
Bone (PMCB) graft
Longer healing period
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Anatomic Structures of Edentulous

Maxilla and Mandible

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Anatomic Structures of Edentulous

Maxilla

Nasal cavity
Maxillary sinus
Incisive foramen
Greater palatine foramen

Peri-implant bone thickness

: more than 1 mm
Alveolar bone width
: more than 5~6 mm
Vertical alveolar bone height
: more than 10 mm
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Resolutions of Anatomic Limitation

in the Anterior Maxilla
Narrow alveolar & Vertically atrophic ridge

Small diameter fixture

Osteoplasty
GBR
Ridge expansion osteotomy (REO) procedure
Split crest (ridge splitting) technique
Veneer (saddle) bone graft
Antral-nasal inlay graft
Interpositional bone graft with Le Fort I osteotomy
Alveolar distraction
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Ridge Expansion Osteotomy (REO)

Indications
Cancellous maxilla
Narrow ridge, wider than 4 mm in B-P width
(Ridge expansion effect : 1 ~ 2 mm)
Immediate implantation
Incomplete healed socket

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Ridge Expansion Osteotomy

Intraoperative photographs

Radiographs progression

: REO on anterior maxilla with chin bone graft

Pre-op

Post-op 4mo

Post-op

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Ridge Expansion Osteotomy

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Split Crest Technique

Indication
Narrow alveolar ridge
: wider than 3 mm in B-P width
(Ridge expansion effect : 3 ~ 5 mm)

Healing period : 4 ~ 5 months.

Provisional occlusal loading : 3 ~ 5 months
Success rate : 85 ~ 98 %
Marginal bone loss : 0.5 ~ 1.5 mm
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Split-Crest Technique
Intraoperative photographs
: Split-crest tech. with Mx tuberosity bone graft

Radiographs progression

Pre-op

Post-op

Post-op 1.5 yrs

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Veneer Bone Graft

= Veneer onlay bone graft
Lateral onlay bone graft
Lateral augmentation
Indication
Narrow ridge, less than 3 mm in B-P width
Peri-implant defects (fenestration, dehiscence)
(Ridge expansion effect : More than 3 ~ 4 mm)

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Saddle Bone Graft

Indication
Horizontal and vertical atrophic ridge
: For horizontal and vertical augmentation
(Ridge augmentation effect : 3 ~ 10 mm)

Choice of graft material

Block bone : Chin, ramus, ilium
: Significant less resorption
than particulate bone
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Saddle Bone Graft with Iliac Bone

Post-op 5mon

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Iliac block bone graft & Lt sinus elevation

Preop

Implant installation (Iliac BG + 5 months)

Implant + 4 months (Iliac BG + 10 months)

Postoperative Radiographs
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Resolution of Anatomic Limitations

in the Posterior Maxilla
Vertically Atrophic Ridge
Short, wide diameter fixture
Onlay bone graft
Interpositional bone graft with Le Fort I osteotomyt
Zygomaticoalveolar implant
Mx sinus floor elevation
: OSFE, BAOSFE, and subantral bone graft
Vertical alveolar distraction (?)

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Protocol of Maxillary Sinus Elevation

Residual bone height

Methods

Timing of installation

> 9 mm

OSFE (0-2mm)

Simultaneous

9 ~ 7 mm

BAOSFE (2-4mm)

Simultaneous

7 ~ 3 (5) mm

One-step lateral window

Simultaneous

< 3 (5) mm

Two-step lateral window

One-step with block bone

2nd step 3 - 4 mo later

Chonnam Univ. Hospital

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(Oh)

One-Step Sinus Elevation

( Window Technique)

Indication

3(5) ~ 7 mm in residual bone height

: Use particulated bone graft
Less than 3 mm in residual bone height
: Use block bone graft
Stable initial implant fixation
No maxillary sinus infection

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One-Step Subantral Bone Graft

2005. 5. 23.
Extraction on #13-23, 35-47
Both sinuses elevation with both ramal bone graft
Implant installation on #12i-16i, 22i-26i
Temporary implant (4X) installation

2005.8.5.
Implant installation on #32i-37i,42i-47i
Temporary implant (4X) installation

Residual bone H.: 3mm

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One-Step Subantral Bone Graft

: Sinus elevation with ramal & Mx tuberosity B/G, temporary implant
Implant installation on the lower jaw & temporary implant

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One-Step Subantral Bone Graft

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One-Step Subantral Bone Graft

Post-op 1.5 yrs

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Two-Step Subantral Bone Graft

Indication

Less than 3 mm in residual bone height

Unstable initial implant fixation
Maxillary sinus infection
Additional bone graft (onlay graft)

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Two-Step Subantral Bone Graft

Pt: Kim 0 0 (53/M)
PMH: HTN & DM (Med. for 10 yrs)
Imp: Edentulous state on #14-17, #24-27, #37-47,
& chronic severe periodontitis
HxPi: 04. 2.17. OMS visit
04. 2.23. Ext of #11-13, 21-23,
implant on #32i-36i, #42i-46i,
onlay bone graft on Rt alveolous,
& both sinus elevation with chin bone
04. 8. 7. Implant on #12i-16i, #22i-26i
05. 1.20. 2nd Surg.

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Two-Step Subantral Bone Graft

Both sinus elevation with chin bone,
Onlay bone graft on Rt alveolous, Implant on #32i-36i, #42i-46i,

Post-op 5mo

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Two-Step Subantral Bone Graft

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Post-op 1.5 yrs

Two-Step Subantral Bone Graft

Post-op 1.5 yrs

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Anatomic Structures of Edentulous

Maxilla and Mandible

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Anatomic structures of edentulous

mandible

Mental nerve
Inferior alveolar nerve
Atrophic ridge

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#35i

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Resolutions of Anatomic Limitation

in the Mandible
Narrow & Vertically Atrophic Ridge

Small diameter fixture

Osteoplasty
GBR
Ridge expansion osteotomy (REO) procedure
Split crest (ridge splitting) technique
Veneer (saddle) bone graft
Vertical alveolar distraction
Inferior alveolar nerve repositioning

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Osteoplasty
Pt: La 0 0 (71/F)
Imp: Full edentulous state on both jaws
HxPi: 04. 6.17. Implant on #32i,33i,42i,43i
for bar-retained overdenture
04. 11.2. 2nd Surg.

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Osteoplasty

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Osteoplasty
Post-op 2 yrs

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Inferior Alveolar Nerve(IAN) Repositioning & DO

Pt: Kim 0 0 (46/F)
Imp: Atrophic ridge on both side of lower posterior,
Edentulous state on # 34-37
HxPi: 95. Extraction of #17, 34-37, 44-47
05. 1.12. Rt IAN reposition,
implant on #44i, 45i, 46i,
& Lt alveolar DO device delivery

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IAN Repositioning & DO

Dental CT Findings : 2005. 1. 6. (pre-op)

: 4mm, 5mm

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IAN Repositioning & DO

Intraoperative photographs

: Rt IAN transposition, & Lt alveloar DO device delivery

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IAN Repositioning & DO

Implant prosthesis

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IAN Repositioning & DO

Intraoral photographs progression

Pre-op

Post-op 1.5
yr

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Summary
In the edentulous patients,
1. Many factors, such as jaw relation, inter-arch space, remaining bone,
anatomical structures, soft tissue and so on, should be considered.
2. In old patients, general condition is primarily considered.
The simple and safe implantation techniques are usually recommended.
3. In the anterior region, the esthetic is primarily considered.
4. In the posterior region, the biomechanics is primarily considered.

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