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Implantation of supporting and retaining structures.

Types of implants, materials.

According to the scientific manual of M. F. Sukharev, R. Sh. Gvetadze, A. M. Shpinova

About indications and contraindications to the use of implantation method

Indications and contraindications for implantation are finally determined after collecting an anamnesis and examination results.

Dental implantation is advisable to carry out with partial loss of teeth with included, end and combined defects of the dentition. In the complete absence of teeth, implantation is indicated for the fixation of fixed and removable dentures. Implantation can be used to eliminate injuries of the maxillofacial region, prosthetics of congenital and acquired facial defects.

The aim of clinical and paraclinical examination methods is to identify contraindications for implantation, of a general and local nature.

When planning implantation   as contraindications  for its implementation should be considered the presence of thyroid pathology,  when there is an increase or decrease in thyroid hormones. With hyperthyroidism, bone resorption occurs due to a decrease in its mineralization level. In diseases of the parathyroid glands, bone resorption is observed due to hypocalcemia and a lack of vitamin IN.

Diabetes -  this is a disease that is associated with impaired insulin synthesis. At the same time, insulin deficiency leads to metabolic disturbances in own bone tissue and a decrease in tissue regeneration.

Diseases of the adrenal cortex,  caused by high production of cortisone, aldosterone and androgens, inhibit osteogenesis. Destruction and violation of bone regeneration are noted with lymphogranulomatosis, leukemia, hemolytic anemia.

Oncological diseases, especially malignant tumors, also relate to contraindications for implantation. In addition, after treatment of cancer, radiation and chemotherapy are usually performed, which reduce the ability of the bone to regenerate and contribute to the development of osteoporosis.

Contraindications for implantation should include mental illness: schizophrenia, paranoia, as well as borderline conditions, in particular neurosis.  It should be noted and the possibility of development carcinophobia  that is, the emergence of the patient's judgments about the relationship of implantation and the possibility of the appearance of cancer.

Alcoholism  and addiction  cause not only a change in the psyche of the patient, but also have a great negative effect on metabolic processes in bone tissue.

When interviewing patients, it is also necessary to identify diseases that reduce the body's resistance to infections. Congenital or acquired diseases that result from disorders in the body’s immune system.  The presence of immunodeficiency virus leads to the destruction of the immune system and the development of inflammatory complications after surgery.

When planning implantation, you must consider bone system diseases  which are mainly found in the manifestations of primary and secondary osteoporosis.

In the presence of metal allergies  it is necessary to conduct preliminary tests to determine the possibility of introducing metal implants and the use of specific metals for implantation and prosthetics.

Thus, absolute contraindications to implantation are determined by the presence of diseases in which the implantation harms the patient’s health and makes it impossible to predict the positive results of implantation and prosthetics.

Particular attention should be paid to contraindications in the presence of diseases of the masticatory-speech apparatus. When planning implantation, it is necessary to carry out preliminary treatment of these diseases to eliminate the risk of inflammatory complications. These diseases include: periodontitis  and periodontal disease, leukoplakia, stomatitis, abnormal types of bite, diseases of the temporomandibular joints.It is also necessary to consider the patient’s presence bruxism  and poor oral hygiene.  During implantation in patients old age  a positive prognosis may be doubtful due to a decrease in metabolic processes in the tissues of the body.

The use of implants as a support for various designs of removable and non-removable dentures substantially depends on the features of the anatomical structure of the bones of the facial skeleton.

Modern designs of dental implants and materials for their creation.

All known implant designs are classified

in form:  cylindrical, screw and plate;

on the surface structure of the intraosseous part:  porous, porous with through holes, porous with a sputtering of titanium or hydroxyapatite;

by design:  non-separable or collapsible implants, with or without a shock absorber;

according to the application method:  for immediate or delayed implantation;

according to the method of connection with the denture:  one-piece and detachable.

The implant design is justified by the toxicological, biomechanical properties of the materials from which they are created, as well as by the capabilities of modern implant production technologies milling, stamping and casting.

In the form of the intraosseous part, the implants can be cylindrical, screw and plate.

In cylindrical implants, the intraosseous part can be solid or hollow when a canal is drilled into it. The surface of the intraosseous part of the hollow implant can be coated with an active coating, and there are holes of various diameters on it. Screw implants are mainly made in a conical shape with a different thread profile. The surface of the intraosseous part has a roughness or coating of the active material. Due to the fact that at the stages of bone regeneration and after prosthetics, unscrewing of implants can be noted, to prevent this, recesses, longitudinal grooves, holes are created on their intraosseous part.

Fig. 1 .    Cylindrical Viutricost Implant:

1 - the mucous membrane;

2 - compact layer;

3 - spongy bone;

4 - the neck of the implant;

5 - grooves on the cylindrical part of the implant;

6, 7, 8 - holes of various diameters;

9 - implant head

Fig. 2.   Lamellar intraosseous implant:

1 - plate part of the implant;

2, 3, 4 - holes of different diameters;

5 - grooves on the intraosseous part;

6- neck of the implant;

7 - implant head;

8 - grooves on the implant head;

9- mucous membrane;

10 - compact layer;

11 - spongy bone

The intraosseous part of the plate implants has a different shape and a machined surface to create the corresponding microrelief. On the intraosseous part of the implant there are holes of various diameters - from 0.5 mm to 3.0 mm, it is believed that their area should not exceed 1/3 of the total surface area of \u200b\u200bthe intraosseous part.

By design, intraosseous implants are divided into non-separable and collapsible.

Non-separable constructions of implants of a cylindrical helical or plate form provide a single complex consisting of the intraosseous part of the implant, from which the neck extends into the support head of the implant.

Collapsible implant designs can also be cylindrical, helical and plate-shaped. Collapsible implants consist of two main elements: the intraosseous part and fixed to it with cement or a threaded connection of the support head. It should be noted that in some constructions of collapsible implants, the presence in the area of \u200b\u200bthe support head of the transition form in the form of a hexagon, which fixes the head to the intraosseous part in a certain position. The fixation of the implant head in this case is carried out by a screw passing through the through threaded channel in the support head.

Collapsible implants have additional elements, such as a dummy screw and a gingival cuff former. The support heads have different tapers ranging from 20 to 40 °, and can be located at different angles - from 10 to 20 ° to the intraosseous part.

At present, support heads made of titanium with a ceramic stump formed on it are being used. In the design of implants it is possible to use shock absorbers in the form of rings, caps, springs. It is believed that the use of a shock-absorbing element can reduce the tension in the bone during chewing load.

When planning implantation, it is necessary to take into account the dimensions of the implant, that is, its length and diameter, which is associated with the volume and density of the bone. The height of the intraosseous part of the cylindrical and screw implants can range from 10 to 25 mm, the diameter from 1.8 to 5.5 mm. The thickness of the intraosseous part of the plate implant is from 1.0 to 1.6 mm, the height of the intraosseous part is from 5 to 15 mm.

In dental implantology, a large number of materials are used.

Implant materials must meet certain requirements, including the absence of pathological changes in the tissues of the body and disturbances in the functioning of organs and tissues throughout the entire period of their functioning.

Implant materials should not have toxic, carcinogenic and allergic effects on human tissues and organs.

To obtain dental implants, biocompatible materials must be used. The implant surface should ensure the adsorption and adhesion of the organic and mineral components of the bone and not inhibit the activity of osteoblasts and osteocytes. Upon contact of the implant surface and bone tissue, a bone, fibro-bone and connective tissue connection occurs. After the implantation of the intraosseous implant, part of its surface is in contact with the osteons and trabeculae of the compact and spongy bone layer, and part of the surface is located in the area of \u200b\u200bthe marrow spaces where the connective tissue will form. The nature of the connection between the implant surface and the bone depends on many factors.

The volume and quality of the surgery affects the healing process of the bone wound. The ability to regenerate bone is determined by the absence of a significant violation of the blood supply and gross damage to the structural formations of the bone (osteons and trabeculae). The nature of bone regeneration will be determined by the shape and material of which the implant is made, the state of the surface of the intraosseous part, as well as the presence of tight contact between the bone and the surface of the implant. After implantation, the density of the connection of the bone with the implant surface is due to the formation of collagen fibers and a physicochemical bond, as a result of the reaction between the mineralized bone matrix and the oxide film layer of the surface of the titanium implant or its hydroxyapatite coating. Of great importance for the structural formation of bone in the area of \u200b\u200bcontact with the implant surface is the effect of chewing load.

The presence of bone and fibrous-bone joints is a physiological response of the bone to the implant introduction and determines its long-term fixation. The formation of only connective tissue connection indicates a bone reaction that does not provide reliable fixation of the implant and determines the possibility of rejection.

In this way, the duration of the functioning of the implant is determined by the biological compatibility of the material of the implant and the presence of a dense bone and fibrous-bone connection.

In addition to the interaction of the implant with the bone, there is its connection with the oral mucosa. The presence of an organic connection between the gum epithelium and the hard tissues of the tooth was suggested by Gottlib (1921) and then this was confirmed by histological studies of G. Yu. Pakalans (1970). Histologically, the connection between the surface of the cervical part of the implant and the mucous membrane of the gums is similar to the gingival connection, but differs in the localization of collagen fibers and the degree of blood supply. Most collagen fibers in the cervical region are oriented along the vertical axis of the implant, and only a small amount mimics the circular ligament. The periosteum and their own plate of the mucous membrane form an insignificant attachment to the cervical part of the implant, mainly the gingival cuffs are created due to gum epithelial cells. The formed and fixed gingival cuff in the area of \u200b\u200bthe implant provides protection against penetration to the intraosseous part of germs and toxins.

It should be noted that for a good fit and the formation of a connective tissue barrier, the cervical part of the implant must be carefully polished, as well as a gentle operation on the mucous membrane. Creating a smooth cervical surface of the implant helps maintain good oral hygiene.

Various materials are used to create implants, but mainly metals are used for this purpose, which must have certain properties, namely: not to undergo corrosion and electrochemical reactions, not to cause pathological changes in body tissues.

A chewing load acts on a dental implant, which can be significant. It is known that the functional endurance of the supporting apparatus of the tooth is different in certain groups of teeth: incisors and fangs from 5 to 20 kg, premolars and molars from 20 to 80 kg. Thus, large vertical and horizontal forces act on the implant when chewing. Therefore, the material from which the implant is made must have a certain safety margin.Strength is the property of a material to withstand the action of external forces without destroying it. A deformation of a solid is called a change in its size and volume, the shape of the body under the action of the applied forces. Deformations of the material, which disappear after external forces and do not cause changes in structure, volume and properties, are called elastic.

Deformations of the dental implant, including the tensile strength and elasticity of the material, must exceed the strength of external influences and withstand dynamic loads. Dynamic loading refers to a chewing effect that alternates with periods of absence.

Inert materials have a physicochemical bond with the bone structure. The implants from which they are created do not collapse in the process of interaction with the surrounding tissues of the body. Inert materials include titanium and its alloys, titanium nickelide, zirconium. Titanium is a lightweight, durable metal with high corrosion resistance. Titanium melts at a temperature of 1690 ° C and has a density of 4.5 g / cm 3, is a non-magnetic metal, has a low coefficient of thermal conductivity and a low modulus of elasticity. An important property of titanium is the spontaneous creation, up to a certain thickness, of an oxide film, which ensures its high corrosion resistance. The oxide layer on the surface of the titanium implant is the basis for the subsequent formation and vital activity of osteogenic cells: osteoblasts, osteocytes, fibroblasts. Titanium is an absolutely bioinert material that does not cause an inflammatory reaction in the body and promotes the formation of bone on the surface of the implant.

In clinical practice, intraosseous implants of titanium nickelide with shape memory effect are used. The shape memory effect is based on a change in the internal structure of the alloy due to rearrangement of the crystal lattice of the material under cooling to a temperature below 10 ° C. After cooling with a titanium tool, the petals of the rod of the cylindrical implant are reduced to full contact, and the petals on the titanium surface of the plate implant are installed in one plane. When an implant is inserted into the bone bed at a temperature of 35-37 ° C, the effect of thermomechanical memory of the alloy is manifested, when the petals move apart and take their primary shape, fixing the implant in the jaw bone.

Zirconium is a strong metal, on the surface of which an oxide and nitride layer is formed, which ensures its high resistance to corrosion. Its main source is zirconium orthoxylate. Currently, pure zirconium is used for the manufacture of intraosseous implants.

The main technological methods for the manufacture of implants include milling, titanium processing by stamping or plastic deformation. By the casting method, subperiosteal cobalt-chrome alloy implants are mainly produced.

Of great importance in the design of implants is attached to the creation of the intraosseous surface, which determines not only the strength properties, corrosion resistance, but also the adhesion of osteogenic cells. The surface structure of the implant significantly affects the creation of contact with the bone and the distribution of stresses in the bone during masticatory loading.

Reliability of long-term fixation of intraosseous implants can be achieved by increasing the contact area of \u200b\u200bthe implant surface with bone tissue by creating a rough surface structure.

Micro-irregularities on the inside of the implant can be created by machining or abrasive treatment under pressure. During mechanical processing (knurling method), the microrelief of the implant surface is formed due to surface deformation when interacting with harder material. Abrasive or sandblasting under pressure is carried out with alumina ceramic powder. After that, to create a more uniform roughness of the implant surface, etching with hydrochloric, sulfuric, and nitric acids is carried out. It is possible to create a rough implant surface using an excimer laser. The implant surface formation can be carried out using plasma spraying technology. Moreover, not only pure titanium powder can be applied to the surface of the titanium implant,   but also   active materials, such as hydroxyapatite or glass ceramics. The result is a coating with a thickness of 30 to 50 microns. To increase the area of \u200b\u200bcontact with the bone by the method of thermal sintering, titanium balls are applied to the surface of Endopor implants.

Ceramic materials are also used as intraosseous implants. An important characteristic of these materials is their high corrosion resistance and good biological compatibility with bone. For the manufacture of intraosseous implants, alumina ceramics are used, which has a single and polycrystalline structure. Monocrystalline sapphire blanks for cylindrical and plate implants are grown in automated installations in vacuum or high purity argon. It should be noted that alumina ceramic implants, despite the high inertness and biological compatibility, are fragile and have a small margin of safety, therefore, ceramic implants are hardly used at present.

Tolerant materials, which include alloys based on cobalt and stainless steel, do not form a physico-chemical connection between the implant surface and the bone, which leads to the formation of a connective tissue layer around the implant. Therefore, their dense, motionless connection with the bone does not occur and there is no good stability after intraosseous implantation.

The basis of the cobalt-chrome alloy is cobalt (66-67%), which has high mechanical properties, and chromium (26-30%), introduced to give the alloy hardness and increase corrosion resistance. The melting point of the alloy is 1458 ° C. Due to its good casting properties, the alloy is used to make cast crown frames, bridges and arches, and is also used for casting the subperiosteal implant frames, which are fixed on the surface of the bone of the upper and lower jaw. In addition to metals, tolerant materials include polymers that do not have toxic and carcinogenic properties (polyethylene, polypropylene).

In the process of creating implants contamination (contamination) of their surface occurs, which depends on the technology of their manufacture and the method of processing the intraosseous surface. The implant surface can be cleaned chemically using a ketone solution. There are cleaning methods in a glow electric discharge and using ultrasonic treatment. Sterilization of the implants is carried out by autoclaving, dry heat method, as well as by ultraviolet irradiation, which allows to achieve a relatively clean surface of the implant.

Types of implantation and surgical features of the introduction of implants.

The surgical stage of treatment should be carried out with strict observance of the rules of asepsis and antiseptics in an operating room or surgery room equipped with the necessary equipment and instruments.

According to the relationship of the implant with hard and soft tissues of the body, various types of implantation.

Endodontic-ossal implantation -   held to strengthen the movable teeth when introduced through the root canal into the underlying bone of the jaw of a titanium pin with various fixation elements on its surface. Implantation can be performed simultaneously with resection of the apex of the root.

Intraosseous (endoossal) implantation -   consists in the introduction of the implant through the mucoperiosteal layer into the bone of the upper or lower jaw. The implant may have a different shape: screw, cylinder or plate. The intraosseous part passes into the neck of the implant head, which is encircled by the mucous membrane of the gum. The support head, on which the prosthetic structure is fixed, protrudes into the oral cavity.

Subperiosteal (subperiosteal) implantation -   carried out by introducing an implant under the mucoperiosteal flap. The subperiosteal implant is a metal frame located on the jaw bone with supporting heads protruding into the oral cavity. Subperiosteal implantation is used for severe atrophy of the bone in the upper and lower jaw.

Intra mucosal implantation -   consists in the introduction of the implant into the mucous membrane of the alveolar process. Intramucosal implants are made of titanium or cobalt-chrome alloy. The implants have a mushroom shape and are fixed on the inner surface of the base of the removable prosthesis. When applying the prosthesis, the implants are inserted into the corresponding recesses on the mucous membrane. Intra mucosal implantation is indicated to improve the fixation of a removable denture, as well as for prosthetics of congenital and acquired facial defects.

Submucosal implantation -   involves the introduction under the mucous membrane of the transitional folds of the oral cavity of magnetic implants to create a valve zone when fixing complete removable dentures. According to the position of the implants inserted under the mucous membrane, magnets of opposite polarity are fixed in the base of the removable prosthesis.

Implantation and subsequent prosthetics are complex dental procedures, therefore, the need for psychological correction and psychomedical preparation of patients is justified. The goal of the doctor’s psychotherapeutic work is to stop anxiety and emotional stress, correct patients' incorrect attitude to dental treatment, and prevent neurotic reactions. When planning implantation, it is necessary to explain to the patient the proposed treatment plan, to demonstrate the implants, photos with the results of implantation and prosthetics.

It should be noted that the implantation operation is associated with pain. The formation of pain includes multicomponent neuro-humoral processes that occur in the central nervous system as a result of exposure to the stimulus. Therefore, during implantation, anesthetic protection of patients is required, including sedation and pain relief. Premedication is based on the use of drugs in preparing a patient for anesthesia or local anesthesia, in order to increase their effectiveness and prevent complications.

The effectiveness of sedation of the benzodiazepine series and sedatives with tranquilizers is confirmed by the normalization of physiological reactions: heart rate and respiration, blood pressure, and activity of the endocrine glands. Psychotropic drugs are widely distributed: phenazepam, diazepam, elenium, phenibut - which are taken 30-40 minutes before the implantation operation. Premedication helps to relieve emotional stress and reduce the emotional perception of pain, while at the same time, the pain itself associated with surgery is reduced slightly, which requires the use of anesthetics.

The implantation operation is performed under local anesthesia, which includes the most common methods: infiltration and conduction anesthesia. Infiltration anesthesia provides anesthesia of the terminal receptors of the second and third branches of the trigeminal nerve and is used for implantation in the upper jaw and in the anterior lower jaw. Conduction anesthesia provides anesthesia in the lateral parts of the lower jaw. Unilateral torus anesthesia is usually performed. The most commonly used local anesthetics are derivatives of a 4% solution of articaine (Septanest, Ubistesin, Ultracain) and derivatives of a 3% solution of mepivacaine (Scanolonest).

Indication for implantation using general anesthesia is the inability to eliminate fear of the upcoming intervention by psychotropic drugs and patient intolerance to local anesthetics.

Depending on the timing of tooth extraction, one can distinguish:

direct implantation    the essence of which is that the operation of implant implantation is carried out simultaneously with tooth extraction; direct implantation can be carried out using non-separable and collapsible implants;

Modern dental implantation is a long process and a patient who dreams of restoring lost teeth needs to be prepared for serious and lengthy work. Depending on the method, quality and quantity of bone tissue, as well as the state of the patient’s body, the implantologist forms an overall picture of the treatment, which will consist of several stages. Naturally, some of them, depending on the method, can be reduced, and some, on the contrary, stretched over a long period of time - all this can only be determined by the attending physician after a face-to-face consultation. Nevertheless, there is a standard set of the main stages of dental implantation, through which more than half of all patients in dental clinics go through.

The first stage: preparation for dental implantation

Features:  This is a mandatory step for every implantation method.

Duration:  from several days to 2 months.

During preparation for dental implantation, it is important for the doctor to understand whether the patient can withstand complex treatment and whether the implant will take root. If there are no obvious contraindications (and this, as a rule, the therapist finds out after examining the patient and tests), then the implantologist begins to study the condition of the oral cavity

Stage two: bone building

Features:is carried out when choosing mainly the classical method of dental implantation, when the patient has an acute shortage of bone tissue and it is not enough to fix the implant.

Duration:  bone building takes several hours, but its engraftment takes at least three months.

Dozens of patients face the need to build bone tissue before dental implants. The jaw bone decreases gradually and imperceptibly, among the main reasons - a long absence of teeth. Even if the tooth was removed a couple of months ago, the patient may already need an increase in bone, both in length (mainly on the upper jaw) and in width (found on both jaws). Bone tissue is noticeably reduced in size due to the lack of load on it. And often, for reliable fixation of a long implant, it is necessary to return to its former dimensions. Bone augmentation is performed by replanting bone or synthetic material. There are several ways for this: open sinus lift (as in the picture), closed sinus lift and bone block grafting.

However, this problem can also be solved by the choice of modern methods in which small structures are used or a special way of installing them: for example, in neighboring areas at an angle where there is enough bone tissue and in deeper layers of bone tissue.

Stage Three: Implant Implantation

Features:  carried out by various technologies depending on the chosen method of dental implantation.

Duration:  from a few days to a year.

The installation of implants is carried out in the following way: the gum is cut, in the bone using special tools creates a bed the size of an implant, where the structure is placed. A stub is placed on top, over which the gum is sutured.

Installation of the implant itself takes only a few hours, but its fusion with the bone is a rather lengthy process, it may take from 4 months to six months, in difficult cases even a year, to complete the healing of structures when the bone and the implant become one.

However, modern methods again significantly reduce the recovery time after surgery and thanks to less traumatic installation methods, for example by puncture, the transition to prosthetics is possible only a couple of days after the operation.

Important! After fixing the implants, it is necessary to switch to soft food, gradually introducing more solid foods into the diet. It is important not to displace the implant and allow it to merge with the bone in a quality manner.

The fourth step: installing the abutment

Features:an abutment is a metal product that serves to connect the implant (it is placed under the gum) and the prosthesis (fixed above the gum).

Duration:  Installation - a few minutes.

Before fixing the abutment, a gingiva former is installed, usually in 2 weeks, then an abutment is placed, a cast is taken to make a future crown.
  Express implantation methods involve the use of implants that are already combined with the abutment. Thus, when installing structures, their tip remains immediately above the gum.

Fifth stage: prosthetics

Features:  any prostheses can be fixed on implants - from a single tooth crown to a full-fledged design for the entire dentition.

Duration:few hours.

After the implants have taken root, the abutment is installed, the most pleasant moment of treatment comes - the installation of artificial teeth, which will act as visible crowns. Depending on the method, this stage occurs either after the implant has grown together with the bone, or almost immediately - 2-3 days after the implants are directly installed.

The timely detection of crowded teeth pathology is one of the important tasks of a dental examination. Diagnose abnormally growing teeth can be visually, using an x-ray or when passing a tomograph. The sooner this defect is discovered, the easier and faster it can be fixed.

About pathology

Crowding of teeth is the result of abnormal formation of the dentition. The teeth do not just grow densely to each other - there is no free space between them at all, as a result of which they:

• overlap each other;
• turn around its axis;
• go beyond the jaw arch.

This pathology can undergo the entire dentition or its individual fragments, both in the upper and lower jaw. Crowding of the teeth is diagnosed with layering of teeth on each other from 2-3 mm.

Causes

The factors that provoke crowding can be incorporated in the human body even at birth, these are:

• extremely small jaw volume;
• the appearance of extra teeth in those places of the dentition where they should not be;
• oversized incisors.

The reasons that arise in the process of life and are considered acquired:

• excessive use of nipples in infancy;
• breathing not through the nose, but through the mouth;
• rickets or other problems that interfere with the proper formation of the body;
• non-standard teething of individual teeth.

Braces

Among the possible options for correcting crowding, the use of bracket systems is the most popular. Using this method, you can:

• expand the interdental space;
• make the tooth tilt to the planned angle in the right direction;
• move the frontal teeth in the direction of the posterior.

Depending on the complexity of the abnormal shifts after an X-ray examination, the dentist determines the time required for proper stabilization of the entire series, and the type of bracket system used. In especially difficult cases, when there is no free space in the jaw, correction of the pathology with the help of braces is impossible without the removal of one or several teeth.

Can I do without braces?

A mild degree of pathological changes can be corrected by separation. The separation technique consists in gentle grinding of tooth enamel. A non-traumatic surface turning can create a free interdental space, sufficient to correct a simple pathology.

Slight deviations from the standard arrangement of individual units in the dentition can correct lumineers or veneers. These are special overlays in the form of plates of different thicknesses. They can be made of porcelain, ceramic or composite material.

Removal of teeth in pathology

  A radical method for relieving symptoms of crowding is a surgical operation to remove the required number of teeth in a specific place. As a result of the removal, interdental tension is removed, and the remaining teeth diverge, occupying the vacant space.

The most likely objects to be removed first are wisdom teeth. It is generally accepted that they do not play a big role in the chewing process and during the operation of the speech apparatus.

What will happen if not treated?

The lack of interdental space makes it difficult to diagnose and treat various inflammatory processes in the oral mucosa. Also, in the absence of timely and qualified treatment, crowding of the teeth leads to the appearance of:

• malocclusion;
• plaque and stone formation;
• caries and periodontitis.

Types of implants and methods of their installation affect the time of surgery and implantation of implants in the tissue. But not every one of them will suit you, since each implant is designed for a very specific case.

You can not choose implants only on the basis of how quickly they are installed or implanted in the tissue of the jaw. The individual characteristics of the bone tissue and the shape of the jaw of the patient are always taken into account.

Common to all methods is the sequence of actions concluded in a process called dental implantation. All implantology adheres to this scheme.

Often people ask how many implants can be placed at a time?

Ten or more, but remember that this is still an operation, albeit a simple one, and the body gets stressed.

In general, the scheme can be represented as a sequence of such stages of dental implants:

1. Assessment of the condition of the body for the presence of contraindications for surgery.
  2. Preparatory or preoperative.
  3. Surgical.
  4. The stage of installation of the abutment on the implant.
  5. Orthopedic.

  Let us consider in more detail all the stages of dental implantation and their order.

1st stage: assessment of the state of the body

At the first stage, the doctor examines the patient, identifying the causes of possible complications after dental implants. The presence of diseases that exclude the possibility of surgical intervention is determined. Several types of tests are done, according to the results of which the doctor concludes that the patient is indicated or impossible to implant.
  At this stage, attention is paid to the condition not only of the oral cavity, but also of other organs. A general blood test, a blood test for sugar, a test for hepatitis and HIV are carried out, x-rays are taken.

Stage 2: preparation for implantation

In the absence of contraindications for implant placement, the second stage of dental implantation is performed, which consists in preparing the oral cavity for the upcoming operation.
  At this stage, the patient undergoes an examination of the oral cavity, identification of diseased teeth and old crowns to be replaced. Patient teeth are treated, old crowns are replaced with new ones, and if there are problems with gums, medical procedures are also carried out.
  After preparatory steps, the implantologist develops a plan for the preparation and conduct of the operation: a panoramic picture of the jaw (orthopantomogram) and a three-dimensional projection of the jaw (computed 3D tomography - CT, if necessary) are taken.
  These images reveal problems of the jaw and intra-gingival tissues.
  With their help, such diseases are found that it is difficult to see without special means, for example, granulomas and cysts. And also determines the quality and size of bone tissue. Using images is easier to decide where and how to install the implant.

3rd stage: surgical (directly installing the implant)

In the third stage, surgical operations are performed based on the information obtained in the second stage. Often this is the stage that excites patients most of all, and they want to know whether it is painful to insert dental implants and is it worth putting them on? This question can be answered as follows: today medicine has stepped far forward and pain is minimized.
  In case of deficiency of bone tissue, a closed or open sinus lift procedure is performed. Bone becomes weaker with age. The mass of tissue decreases and becomes more porous. The bone also decreases in size when quite a lot of time has passed after tooth extraction. Reliable attachment requires a sufficient amount of bone tissue. The gingival bone, with this procedure, increases, both in height and in length and width. The procedure itself can last several hours. After it, the bone should “accept” the composition. The healing process can take from one to three months.
  Now, for this procedure, modern, most convenient methods using small structures are used.
  With some methods of implantation, even with minimal bone mass, you can install the implant without additional bone growth.
  After complete bone engraftment, the implant installation procedure begins. Depending on the type of implant, an incision or puncture of the gums is performed. A recess is made in the gingival bone with a diameter suitable for the implant. The design is being introduced into it. A plug is installed on the implant. The gum is sutured or, if there was a puncture, grows together.
  Installation, depending on the method and type of implant, lasts from half an hour to several hours. After installation, in the period from several months to a year, the implant takes root. In some cases, thanks to new methods of implantation, this period is reduced to several days.

4th stage: installing the abutment

At the fourth stage, a special element is installed for subsequent fastening of the prosthesis on it. This is an abutment (take a look at the photo). It is selected and mounted on the implant as the prosthesis of the tooth will subsequently be installed. That is, the size and angle of the implant must match the specific jaw. Therefore, for each implant
Several types of abutments are produced at once. Installing an abutment takes a few minutes. Two weeks before the installation of the abutment, a gingiva former is placed. It is placed temporarily after implantation. A few days later, an abutment is installed in its place.
  Now some types of implants are available immediately connected to the abutment.

5th stage: orthopedic

After installing the abutment, a cast is made from both jaws to make the prosthesis.
  This is the beginning of the last stage - orthopedic. According to the cast, a crown is made on a tooth, or a bridge, imitating a row of teeth. The color of the artificial tooth is selected. The prosthesis may be removable or non-removable.
  The prosthesis procedure takes several hours (including the manufacture of the prosthesis). Immediately after installing the prosthesis, it can be involved in the process of chewing food without fear.
  It should be remembered that the operation of installing implants is not cheap. The price includes the cost of both the implants themselves and the services of an implantologist. It is also worth considering the popularity of the clinic you contacted if you want to have a dental implant.
  Remember that the mandatory implementation of the doctor’s recommendations for the care of new prostheses is a guarantee of a long service of implants.

General principles of implantation

The fundamental principle of implantation is an atraumatic technique. This is a principle that applies to all surgical interventions and in relation to any tissue, but it becomes of paramount importance during implantation. A sparing attitude to tissues is of the same importance in creating the conditions for their healing and in the prevention of complications, as is the implementation of asepsis rules. Any surgical wound, including bone, can heal by first intention only if aseptic is followed and surgical intervention is performed with the minimum possible tissue trauma, and none of these conditions can be replaced by the use of antibiotics or other drugs. In implantology, knowledge of the general issues of operating technique and mastery of elementary techniques for dissecting tissues, detaching mucoperiosteal flaps, preparing bone tissue and suturing the wound is especially important, since the healing of the surrounding tissues depends on how non-invasively the operation was performed, and it means the success of both the operation itself and the treatment as a whole. Atraumatic surgical technique during implantation is not an abstract concept, but rather a series of measures that include not only careful handling of tissues, but also the right choice of surgical access, strict adherence to the rules for the preparation of the implant bone bed and closure of the surgical wound.

Section and providing operational access to the alveolar ridge. Dissection of the mucous membrane and periosteum is usually done along the crest of the alveolar process. In this case, two mucosal-periosteal flaps are exfoliated, thus providing quick access to the alveolar process of the jaw. An incision can also be made in the region of the vestibule of the oral cavity with a detachment of one mucoperiosteal flap, but only if the thickness of the mucous membrane does not exceed 2 mm and in the absence of a pronounced scar formed after tooth extraction in the region of the ridge of the alveolar process, as well as sufficient depth of the vestibule. A technique called “bloodless” may also be used. In this case, quick access is via the excised section of the mucous membrane and periosteum in the area of \u200b\u200bthe crest of the alveolar process. The bloodless technique is more often used when using single-stage implants, but recently it has found widespread use in two-stage implants.

Preparation of a bone bed. The general principle for all implantation techniques is strict observance of the rules for atraumatic preparation of the bone bed. Depending on the type and shape of the intraosseous part of the implant, the techniques may differ from each other in the details of the preparation of the bone bed. Preparation of the bed for screw or cylindrical implants should be performed with specially designed drills with a low speed of rotation (1000 1500 rpm); under the blade with a circular saw and special fissure burs at high rotation speeds (30,000 35,000 rpm). It is necessary to prepare the bed in stages, with a graduation of the tools but with a diameter and constant irrigation of the preparation zone with a cooling solution, which can be done using a peristaltic pump with an internal and external tip connected to the system or using a 20 ml syringe with a long blunt needle (cannula). It is very useful to collect bone chips from the outlet grooves. Firstly, it will ensure normal drilling and prevent bone heating. Secondly, the collected bone chips placed in a Petri dish and moistened with physiological saline can be useful for building bone tissue, correcting the contour of the alveolar ridge in the area of \u200b\u200bimplantation, or solving some problems and complications that may occur during surgery.

Implant placement The implant must be installed in a bone bed appropriate to its shape and size. In this case, it is necessary to ensure primary fixation of the implant and complete immersion in the bone tissue of its intraosseous part. The components of the installed implant should not impede the closure of the surgical wound and cause tension of the mucoperiosteal flaps when it is sutured.

Closure of the wound. It is made by overlaying nodal or mattress seams from non-absorbable synthetic materials (Yicril, Dexon, Dafilon, etc.). It is not allowed to twist the edges of the wound, the presence of a gap between the edges of the flaps, as well as their excessive compression, especially mattress sutures. When using non-separable, as well as designed for a one-stage method of implant placement, it is necessary to ensure a tight fit of the mucoperiosteal flaps to their corresponding parts. To do this, part of the edges of the flaps in the implant area is excised and sutures are placed from the part protruding into the oral cavity to the distal sections of the surgical wound.

Basic Operation Techniques

There are one- and two-stage implantation techniques, which are basic, standard interventions. The essence of the two-stage technique is that first they install the intraosseous element (the first stage of the operation). The second stage of the operation consists in excising the mucous membrane above the intraosseous element, installing the shaper of the gingival cuff, head or other orthopedic component provided by the implant design. In a one-step technique, the support head (non-separable structures) or the module to which the head (collapsible structures) will then be fixed, protrudes into the oral cavity.

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