Bone grafting procedures for osseous defects associated with dental implants.

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Slide 1 :

Bone grafting procedures for osseous defects associated with dental implants. Gagik Hakobyan MD PhD

Slide 2 :

Clinical efforts to achieve osseointegration are directed toward maximizing vital bone at the implant surgical interface, limiting inflammation, and preventing micro motion at the implant/tissue interface. Two main aberrations may result in defective osseointegration. First, during the healing phase, the inability of the bone bed to establish adequate mechanical contact with the implant surface results in a layer of intervening connective tissue. Second, the development of a pathological process similar in principle to periodontitis leads to an accelerated loss of supporting structure via a centripetal path of infection.

Slide 3 :

Bone quality plays a major role in determining the success of the dental implant. Poor-quality bone and some diseases are universally recognized as risk factors. Radiolucent areas, draining fistulas, symptoms of osteomyelitis, fracture sites less then a year old, metabolic bone disease, clotting disorders all are contraindications for implant placement Implant failures as a result of overload or infection give rise to bone loss.

Slide 4 :

There are three identifiable types of failure; the first of which is ‘biological’, and can be described as the inability of the host to ‘establish or maintain osseointegration’ and could result in early or late failures; the second is ‘biomechanical’ from prosthetic or functional overload, and thirdly ‘iatrogenic’ from poor implant position or proximity to anatomic structures.

Slide 5 :

Early implant failures are most commonly related to surgical trauma and/or inadequate bone quality or volume, whilst late failures are determined more by functional loads in relation to the quality of the supporting hard tissues and any tendency toward chronic and /or infections.Failure was caused by an infectious process that most likely started along the midportions and apical portions of the implant body. The organism could have been introduced into the site either at a later time of surgery or at a later time via a hematogeneous route. These lesions differ from periimplantitis in that the infectious process originates at the implant interface within the alveolar bone.

Slide 6 :

The removal of chronic infection centers in jawbones plays very important role prior to implant surgery and influences on the advancement of the efficiency of implantation. Different clinical situations merit careful consideration of the surgical and restorative approaches taken during the process of tooth replacement using dental implants. Radicular jaw cysts occupy an essential place in the practice of oral and maxillofacial surgery. In the situation of large cysts it is necessary to fill the remaining cavity with bone substitute materials to obtain a correct anatomic form and satisfactory mechanical strength.

Slide 7 :

Purpose of this study was to clinically and radiologically evaluate the use of bone grafting therapy for treatment of osseous defects prior to implant surgery. Qualitative and quantitative classification of bone by Mish and Judy 1987,Lekholm and Zarb 1985,were used for selection of implants size and types for placement Treatment of osseous cysts requires intraosseous access that is obtainable at the expense of removing cortical bone formation necessitating reconstructive procedures with grafts. This technique obviates the use of biocomposit preparats, barrier membranes in the treatment of large cysts, apical resection areas and facilitates, the dental rehabilitation with the osseointegrated implant in second surgery.

Slide 8 :

. Selection of implant size and location was based on clinical and radiographic evaluation, with the aim to place the longest and widest implant. Blade-form implants were commonly used in case of narrow alveolar ridge (with less than 4mm) at the distal part of mandible. All implants were inserted using recognized surgical procedures and according to manufacturer’s protocol. Maxillary screw implants were left for six months, and mandibular screw implants for three months, after which they were exposed and restored according to conventional implant protocol. Blade-form implants loading after one-month operation.

Slide 9 :

CASE REPORT History and clinical examination A 45-year-old male patient seeking implant rehabilitation presented with partially maxillary and mandibular edentulous. Partially dentures had been used for two years without satisfaction. Clinical and radiographic examinations were conducted. An updated health history was reviewed to evaluate the patient’s present health condition and to rule out diseases or other factors that would contraindicate bone graft or dental implant surgery. A panoramic radiograph showed a cystic radiolucency from the left central and lateral incisors (tooth#9, 10) to the left canine (tooth#11) region of the maxilla. Right mandibular first premolar (tooth#28) present with a large endodontic-periodontal lesion, left mandibular canine, first and second premolar presents with remaining restorable roots (tooth#20, 21, 22) (figure 1). Clinical and radiographic examination revealed adequate bone height and width in the maxillary edentulous region for screw implant placement and narrow alveolar ridge (with less than 4mm) at the distal edentulous region of mandible.

Slide 10 :

(Figure 1). A panographic X ray showed a cystic radiolucency from the right central and lateral incisors (tooth#9,10) to the right canine (tooth#11) region of the maxilla. Right mandibular first premolar (tooth#28) present with a large endodontic-periodontal lesion, left mandibular canine, first and second premolar presents with remaining restorable roots (tooth#20,21,22) .

Slide 11 :

Treatment plan After diagnostic records and patient consultation cystectomy and apicoectomy procedures was planned using bone graft material Collapan (hydroxylapatite combined with collagen and antibiotic linkomycini hydrochloridum) (Intermediapatit Moscow RF) before implant surgery. An initial treatment plan was presented to the patient. The plan included the restored tooths#20,21,22, surgical removal of the maxillary cyst and apicoectomy toot # 29 with subsequent bone grafting of the defect . After one month bone graft therapy of osseous defects, two HA coated titanium endosseous two stage screw implants in 13, 14 tooth region maxilla and two HA coated blade-form implants 19, 31 tooth region mandible placement planed.

Slide 12 :

Surgical procedure The patient was orally premedicated with 2g of amoxicilin 1 prior to the procedureand given oral sedation 10mg of Valium. Prophylactic antibiotics six days postoperative.The patient was anesthetized with local anesthesia in maxilla and inferior alveolar nerve block anesthesia which included Ultracain D-S forte (Hoechst Marion Roussel). After incision and elevating a mucoperiosteal flap, a fissure bur was then used to section vestibular wall osseous cyst. Granulation tissue was removed from cyst cavity (Figure2, 3). This was accomplished using a titanium curette and the site irrigated with saline and antibiotics. After degranulatin and antiseptic preparation bon defect was filled with particles, gel of Collapan (Figure6). It was then covered with a Capset Calcium Sulfate bone graft barriers membrane (Lifecore Biomedical. Inc. USA.). The area was sutured by continuous cross using a 3-0 material (Vicryl, Ethicon, Inc. Somerville. N.Y). The patient was instructed to use chlorhexidine mouth rises twice daily for two weeks to reduce the risk of infection. Seven days later, the sutures were removed.

Slide 13 :

After incision and elevating a mucoperiosteal flap, a fissure bur was then used to section vestibular wall osseous cyst (figure 2,3). (Figure 2). (Figure 3). Granulation tissue was removed from cyst cavity (figure 4). (Figure 4). (Figure 5). Removed cyst from cyst cavity(figure 5). .

Slide 14 :

After degranulatin and antiseptic preparation bone defect were grafted with granules and gel Collapan(figure 6,7). . Figure 6. Figure 8. The area was sutured by continuous cross. Figure 7.

Slide 15 :

Titanium HA coated blade -form implant and screw implants were inserted. (figure 9,10). Figure 9. Figure 10. Figure 11. Figure 12. Healing plugs were inserted in screw implants. Flaps were repositioned sutured (figure11,12). .

Slide 16 :

Figure 13. Postoperative panographic X ray

Slide 17 :

Metaloceramic reconstruction was fabricated and fixed in tooth and implant abutments (figure14,15,16,17). Figure 14. Figure 15. Figure 16. Figure 17.

Slide 18 :

Metaloceramic reconstruction was fabricated and fixed in tooth and implant abutments. Figure 18 Figure 19 Figure 20 Abutments were inserted in screw implants.

Slide 19 :

Figure 21. Panographic X ray of final restoration. The histological section revealed mature bone surrounding remaining crystals of particles Collapan. Figure 22.

Slide 20 :

RESULTS Success implantation was established by using parameters established by Albrektsson et al. Failure criteria included mobility, pain, implant loss, and peri-implant radiolucency. No immediate postoperative complication (infection, persistent pain or bleeding) occurred on any of the bone graft procedures. There was no foreign-body reaction to the materials within the bone. Five-year follow-up results revealed stability of implants, good quality of underling bone, absence of inflammation at the peri-implant zone and positive dynamics of osseointegration.

Slide 21 :

In this case it was possible to demonstrate the higher efficacy and osteoconductive properties of Collapan for repairing periimplant intrabony defects. The medical effect of Collapan is caused by its osseogenial properties: the preparation contains high-purity collagen and hydroxylapetite, which is a matrix for again formed bone fabric. Histology demonstrated all particles Collapan to be surrounded by newly formed bone, osteoid (figure 22).

Slide 22 :

Presence of the centers of a chronic infection in periapical fabrics will be the cause of infringement of blood circulation, hypoxia of fabrics and will also change the general reactance of an organism and a sensitization. Among inflammatory diseases of maxillofacial area, root cysts and periapical destructive processes take rather appreciable place. It’s very urgent to remove the bone defect after the operation, which is determined by duration of healing and rather high frequency of purulent complications of bone wounds. It is known that, after removing a average or a big size cyst, during a healing of bone wound, under the bloody grume there is no filled bone defect, which reduces the durability of a bone and the thickens of a alveolar ridge.

Slide 23 :

Several factors were regarded critical to the success of the bone grafting procedures for osseous defects prior to implant surgery. 1) good isolation of the surgical site to prevent contamination; 2) a traumatic handling of the soft tissue; 3) reflection of full muco-periosteal flaps; 4) good compression of the bone graft material to eliminate voids; 5) ensuring haemostasis with intra-oral pressure dressings for 10-15 minutes; 6) proper suturing techniques to provide good apposition of the soft tissue; 7) thorough post-operative instructions to the patient.

Slide 24 :

After surgical treatment of the chronic odontogenic centers with the use of biocomposite materials, the restoration of bone defects increases the efficiency of implant placement, prevent the complications and reduces the healing period. Reconstructive surgical techniques are reliable procedures for optimizing the implant treatment in cases of bone defects. The results showed that in all cases the defect was eventually filled with newly formed bone although at a very slow rate. The received results testify of high efficiency of methods of bone grafts at the stages of preparation, carrying out the dental implantations and essentially expand the indications of given kind of treatment.

Slide 25 :

GAGIK HAKOBYAN MD PhD DIRECTOR OF THE MEDICAL CENTER PROMETEY , ARMENIA ASSOCIATE PROFESSOR OF THE DEPARTMENT OF SURGICAL STOMATOLOGY STATE MEDICAL UNIVERSITY OF YEREVAN ASS.MEMBER OF THE EUROPEAN ASSOCIATION FOR CRANIO-MAXILLOFACIAL SURGERY ( EACMFS ) CORRESPONDENCE TO DR. G. HAKOBYAN 375028 KIEVYAN 14A YEREVAN, REPUBLIC OF ARMENIA MEDICAL CENTER PROMETEY Tel( 3741) 271146 Fax (3741) 274983 e-mail: prom_hg@yahoo.com

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