Implants in orthodontics
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INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com
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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 . www.indiandentalacademy.com
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8. Biomechanics in implant dentistry. 9. Complications with implants . 10.Uses of implants - Medical . - Orthodontic . 11. Conclusion .
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INTRODUCTION
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ďƒ˜ For centuries man has dreamt of replacing missing teeth with artificial substitutes that restore the normal function, comfort, esthetics, & speech. ďƒ˜ Implants make that dream come true .
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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.
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HISTORICAL BACKGROUND
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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. www.indiandentalacademy.com
 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.
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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 . www.indiandentalacademy.com
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.
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IMPLANTS Nomenclature & Classification. www.indiandentalacademy.com
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.
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Parts of an implant
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Gold screw Gold cylinder
Abutment Cover screw Fixture www.indiandentalacademy.com
CLASSIFICATION
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Implants Endosteal
Subperiosteal
Transosteal
Root form Plate/blade form Endodontic stabilizer
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Endosteal implant Endo – within
Osteal – bone -: alloplastic material surgically inserted into a residual bony ridge, primarily to serve as a prosthodontic foundation.
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ďƒ˜ Endosteal implants comprise one broad category of implants . ďƒ˜ The most commonly applicable abutment providing modalities are endosteal. ďƒ˜ The endosteal implants are placed within a fully or partially edentulous alveolar ridges with sufficient residual bone available.
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ďƒź Some endosteal implants are attached to components for the retention of a fixed or removable prosthesis. ďƒź Other implants are equipped with an abutment integral with the implant body, which protrudes into the oral cavity during healing.
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Root form implant ďƒ˜ These are designed to resemble the shape of a natural tooth root. They usually are circular in cross section . ďƒ˜ 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 .
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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. www.indiandentalacademy.com
Plate / Blade form implant ďƒ° 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. ďƒ°They are unique among implants in that they can function successfully in either osseointegration or osteopreservation mode of tissue integration. www.indiandentalacademy.com
Plate/blade form implants
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Endodontic stabilizer implants
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The endodontic stabilizers function in the osteopreservation mode of tissue integration
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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 .
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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.
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Ramus frame implants Often intended for treatment of total mandibular edentulism with severe alveolar ridge resorption.
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DIAGNOSIS & TREATMENT PLANNING
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Consultation  Chief complaint  Patients Goals of Treatment
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Clinical Examination Medical examination Radiography Diagnostic Models
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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 www.indiandentalacademy.com
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 www.indiandentalacademy.com
BONE PHYSIOLOGY & METABOLISM.
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ďƒ˜ 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. ďƒ˜ Phylogenetically the original purpose of internal stores of mineralized tissue was to serve as a physiologic reservoir of calcium.
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ďƒ°Bone is a highly ordered composite of organic matrix & inorganic material. ďƒ°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) www.indiandentalacademy.com
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 www.indiandentalacademy.com
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. www.indiandentalacademy.com
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 .
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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.
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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.
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PRINCIPALS OF IMPLANTS.
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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. www.indiandentalacademy.com
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. www.indiandentalacademy.com
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. www.indiandentalacademy.com
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.
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Fibrointegration
Osseointegrtion www.indiandentalacademy.com
BIOMATERIALS IN IMPLANTS
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Biocompatibility It is defined as an appropriate response to a material (biomaterial) within a device (design) for a specific clinical application.
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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.
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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 . www.indiandentalacademy.com
In 1990’s – Emphasis has been on chemically & mechanically anisotropic substrates combined with growth (mitogenic) & inductive (morphogenic) substances.
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characteristics of implant material Physical & mechanical properties – Forces exerted on implants consists of – Tensile Compressive Shear components.
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Parafunction can be greatly detrimental to longivity because of mechanical properties like – Maximal yield strength . Fatigue strength . Ductility. Creep deformability & Fracture. www.indiandentalacademy.com
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 .
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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.
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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.
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Toxicity – Is related to primary biodegradation products (simple & complex cations & anions) , particularly those with higher atomic weight metals.
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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. www.indiandentalacademy.com
CLINICAL BIOMECHANICS IN IMPLANT DENTISTRY
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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
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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.
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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. www.indiandentalacademy.com
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. www.indiandentalacademy.com
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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.
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3 types of forces – 1. Compressive. 2. Tensile. 3. Shear . Compressive – compressive force tends to maintain the integrity of a bone to implant interface . www.indiandentalacademy.com
ďƒ˜ Tensile & shear forces tend to distract or disrupt such an interface. ďƒ˜ Shear forces are most destructive to implant & / or bone when compared to other load modalities. ďƒ˜ Compressive force are best accomodated.
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ďƒ°Cortical bone is strongest in compression & weakest in shear. ďƒ°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 .
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ď Ž 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. ď Ž Bone loss adjacent to cylindrical implant and / or coating degradation results in mechanically compromised implant. www.indiandentalacademy.com
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. www.indiandentalacademy.com
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. www.indiandentalacademy.com
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.
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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.
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Impact loads ďƒ„ When 2 bodies collide in a very small interval of time relatively large reaction force develops . Such a collision is described as impact. ďƒ„ The higher the impact load greater is the risk of implant failure & bone fracture. ďƒ„ Rigidly fixed implants generate a higher interfacial impact force with occlusion compared with natural teeth , which possess periodontal ligament.
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Force delivery & fatigue mechanism ďƒź Duration of force may effect the ultimate outcome of an implant system. ďƒź Relatively low magnitude forces applied repeatedly over a long time ,may result in fatigue failure of an implant / prosthesis.
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COMPLICATIONS
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Soft tissue complications Infection Exposure of cover screw. Gingivitis. Exposure of the fixture threads.
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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. www.indiandentalacademy.com
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. www.indiandentalacademy.com
IMPLANT SURGERY
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Incision
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Mucoperiosteum raised
Neurovascular bundles www.indiandentalacademy.com
Perforation of the cortex
Preparation of the site www.indiandentalacademy.com
Preparation of site
Insertion of the implant www.indiandentalacademy.com
Implants placed
suturing
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Location of the implants
Healing abutments www.indiandentalacademy.com
Cover screws exposed through punch incision
Healing abutments inserted www.indiandentalacademy.com
Healing abutments removed to reveal peri implant cuff.
Assessment of soft tissue depth www.indiandentalacademy.com
Abutments
Abutments www.indiandentalacademy.com
Final abutments
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USES OF IMPLANTS
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CONGENITALLY ABSENT EAR
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Congenitally absent ear
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AURICULAR PROSTHESIS
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COMBINED EXTRAORAL & INTRAORAL PROSTHESIS
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Pre-treatment
Implant with bar
Post-treatment
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UNILATERAL CLEFT LIP & PALATE
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Pre-treatment
Pre-treatment
Posttreatment
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OCULAR PROSTHESIS
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Ocular prosthesis
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NASAL PROSTHESIS
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Pre-treatment
Endosseous implant
Post - treatment www.indiandentalacademy.com
Rigid Implant Anchorage to Close a Mandibular First Molar Extraction Site W. EUGENE ROBERTS, CHARLES L. NELSON, CHARLES J. GOODACRE,
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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. www.indiandentalacademy.com
Pre-treatment
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$ Post-treatment
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Facial implants
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The use of implants for orthodontic correction of an open bite
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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. www.indiandentalacademy.com
Pre-treatment www.indiandentalacademy.com
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. www.indiandentalacademy.com
Diagnostic set up www.indiandentalacademy.com
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Post-treatment
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Implants as anchorage for molar uprighting and intrusion W. Craig Shellhart, DDS, MS; Maged Moawad, DDS, MPh, MS; Preston Lake, DMD
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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). www.indiandentalacademy.com
Pre-treatment
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Pre-treatment
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Treatment plan use of osseointegrated implants. TPA Mandibular second molars to be tipped distally & intruded. allow the placement of single tooth prostheses bilaterally. www.indiandentalacademy.com
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Post-treatment
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Post-treatment
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Use of maxillary intraosseous implants for Class II elastic anchorage Nile A. Sorenson, Jr, DMD
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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. www.indiandentalacademy.com
Pre-treatment with RPD www.indiandentalacademy.com
Pre-treatment
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With implant www.indiandentalacademy.com
With prosthesis
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Bite opened
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Bridge in place www.indiandentalacademy.com
Post-treatment
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Prediction of mandibular growth rotation A. Bjรถrk, Odont. Dr.
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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.
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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. www.indiandentalacademy.com
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. www.indiandentalacademy.com
Osseointegrated titanium, implants for maxillofacial protraction in monkeys
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Large dots implants
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Extra oral traction appliance
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Tracings solid lines – pre treatment dotted lines – post treatment
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Solid line – end of force application Dotted line – after 4 weeks
Solid line – end of retention Dotted line -10 weeks post retention
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Protraction force applied to splinted maxillary teeth
Skeletal remodeling & sutural expansion
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Zygomatico-temporal suture in control animal
Zygomatico-temporal suture in experimental www.indiandentalacademy.com animal
Traction force delivered to maxillary implant. separation of zygomaticomaxillary suture
Traction force delivered to zygomatic implant. separation of zygomaticotemporal & sphenozygomaticwww.indiandentalacademy.com suture
Traction force delivered to maxillary dentition minimal effect on zygomatico maxillary suture
Traction force delivered to maxillary implant. separation of zygomaticomaxillary suture www.indiandentalacademy.com
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Forced eruption and implant site development: Soft tissue response Theo Mantzikos, DMD, and Ilan Shamus, DDS
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ďƒ˜ A nonsurgical technique for increasing the amount of available bone for implant site development and fixture placement is orthodontic extrusion, or forced eruption. ďƒ˜ 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. www.indiandentalacademy.com
Pre-treatment
Bone-loss www.indiandentalacademy.com
Fixed appliance .018 s.s with step down bend
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Keratinized gingiva bracket placement on cementum www.indiandentalacademy.com
Vertical bone improvement www.indiandentalacademy.com
CONCLUSION
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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. www.indiandentalacademy.com
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