The Problems Of Transplantation In The Distal Region Of The Atrophic Upper Jaw - Implantation Techniques And Case Presentations

Ugradnja usatka u distalnu regiju atrofične gornje čeljusti obično je tehnički zahtjevan kirurški zahvat. Problem najčešće stvara nisko spušten maksilarni sinus. U prezentaciji su prikazane osnove sljedećih kirurških tehnika: 1. zaobilaženje sinusa - ugradnja usatka uza sam medijalni zid sinusa (bez penetracije u sinusnu šupljinu) s blagom distalnom inklinacijom; 2. transkrestalna kondenzacija dna sinusa osteotomima (Summers- tehnika)- kombinirana preparacija svrdlima i osteotomima uz završnu osteotomiju dna sinusa bez perforacije sluznice; 3. otvorena metoda podizanja dna sinusa vestibularnim pristupom - klasičan način pristupom kroz prozor u vestibularnome zidu sinusa, preparacija i potiskivanje sluznice te ugradnja materijala za augmentaciju (istodobno s ugradnjom usatka ili dvofazno). Svaka metoda popraćena je prezentacijom kliničkih slučajeva. Poznavanje svih triju metoda omogućuje iskusnom kliničaru riješiti sve situacije u implantološkom liječenju distalnih regija gornje čeljusti.The insertion of an implant in the distal region of the atrophic upper jaw is usually a technically demanding surgical intervention. Most commonly the problem is a lowered maxillary sinus. The presentation describes the bases of the following surgical techniques: 1. bypassing the sinus - insertion of the implant alongside the medial wall of the sinus (without penetration into the sinus cavity), with slight distal inclination; 2. transcrestal condensation of the sinus floor by osteotomes (Summers-technique) - combined preparation by drills and osteotomes with final osteotomy of the sinus floor without perforation of the mucous membrane; 3. open method of lifting the sinus floor by the vestibular approach - classical method of approach through the opening in the vestibular wall of the sinus, preparation and pressing of the mucous membrane, and inserting of material for augmentation (simultaneously with the insertion implant, or in two phases). Each method is supplemented with a presentation of clinical cases. Knowledge of all three methods enables the experienced clinician to solve all situations in implantological treatment of distal regions in the upper jaw

Therapy of Advanced Periimplantitis - Case Presentation Clinical and Microbial Results after 10 Months

Sve više bude postavljenih usadaka neizbježno je da će biti više komplikacija u vezi s takvim terapijskim postupkom. Jedna od komplikacija koju je najteže izliječiti i koja posljedično može dovesti do gubitka usatka jest bakterijski uzrokovan periimplantitis. U ovome prikazu slučaja opisat će se uspješna terapija uznapredovala periimplantitisa. Pacijent u dobi od 58 godina poslan je parodontologu zbog smetnji u usnoj šupljini u obliku neugodna zadaha te gnojenja oko zuba i usadaka. Prigodom parodontološkoga pregleda opaženo je da su oba usatka na mjestima 22 i 25 zahvaćena periimplantatnim mukozitisom te da postoji krvarenje i gnojenje pri sondiranju. Kod usatka u području 25 postojao je i problem potpunoga nedostatka keratinizirane gingive. Na temelju kliničkog i rtg nalaza te pozitivnog mikrobiološog nalaza na parodontopatogene dijagnosticiran je periimplatitis oko oba usatka. Inicijalna parodontološka terapija završena je u četiri posjeta. Pacijent je dobio upute kako da održava oralnu higijenu te je uključena antiseptička terapija, ispiranje klorheksidinom i uporaba klorheksidinskoga gela izravno u džepove oko usadaka. Kako i nakon takve terapije gnojenje nije prestalo, uključena je i antibiotska terapija te ispiranje džepova jodom. Nakon što je infektivni proces uspješno stavljen pod nadzor, u daljnjem terapijskom postupku proveden je parodontološki kirurški zahvat kako bi se oko usatka 25 pokušao ispraviti nedostatak keratinizirane gingive i dobiti nov pričvrstak. Pošto je režanj odignut, površina usatka očišćena je sterilnom vatom natopljenom u klorheksidin, a s nepca je uzet vezivni presadak te je postavljen na kosti i na izložene navoje usatka. Preko presatka postavljen je Gengigel (hijaluronska kiselina) radi boljeg cijeljenja rane. Pet mjeseci nakon operacije ponovljena je mikrobiološka raščlamba te više nije bilo parodontnih patogena, a klinička mjerenja su pokazala da je smanjena dubina sondiranja, da ne postoji krvarenje ili gnojenje i da je nastala zona keratinizirane gingive od 2 mm oko usatka 25.With the ever increasing number of placed implants it is inevitable that the number of complications connected with such therapeutic procedure will also increase. One of the complications which is hardest to treat and which consequently can lead to loss of the implant, is bacterial caused periimplantitis. This case presentation describes the successful therapy of advanced periimplantitis. The male patient, aged 58 years, was referred to the periodontist because of problems in the oral cavity in the form of unpleasant breath and suppuration around the tooth and implant. During the periodontal examination it was observed that both implants on places 22 and 25 were affected by periimplantic mucositis and bleeding and suppuration occurred during probing. With regard to the implant in area 25 the problem of complete loss of keratinised gingiva was also present. On the basis of the clinical and X-ray findings, and positive microbial test for periodontopathogens, periimplantitis was diagnosed around both implants. Initial periodontological therapy was carried out in four visits. The patient received instructions on the maintenance of oral hygiene and antiseptic therapy was included, rinsing with chlorhexidine and application of chlorhexidine gel directly into the pockets around the implants. As after this therapy the suppuration did not stop antibiotic therapy was included, with rinsing of the pockets with iodine. After successful control of the infective process, further therapy involved a periodontological surgical operation in order to correct the loss of keratinised gingiva around implant 25 and to obtain new attachment. After lifting the flap the surface of the implant was cleaned with sterile cotton wool soaked in chlorhexidine, and from the palate a connective transplant was taken and placed on the bone and the exposed thread of the implant. Gengigel (hyaluronic acid) was placed over the transplant for better healing of the wound. Five months after the operation microbial analysis was repeated. Periodontal pathogens were no longer present and clinical measurements showed reduced probing depth, absence of bleeding and suppuration, and the occurrence of zones of keratinised gingiva of 2 mm around implant 25

Radiographic and Prosthetic Assessment Prior to Implantoprosthetic Therapy

Jedan od osnovnih uvjeta uspješnosti terapije oseointegrirajućim usadcima jest dobro predkirurško planiranje. Svrha je ovoga rada prikazati na slučaju djelomične bezubosti u distalnom dijelu mandibule mogućnosti radiološke i protetske ocjene prije kirurškoga tretmana. Na modelu čeljusti učinjeno je dijagnostičko navoštavanje. Nakon toga izrađena je šablona iz vakuum termoplastične folije. Metalne kuglice poznatoga promjera stavljene su u pozicije navoštanih zuba kako bi se radiološkom tehnikom ocijenila mogućnost implantacije u predviđenim pozicijama. Učinjen je klasični ortopantomogram te na temelju njega i slojeviti tomogram s točnim presjecima mandibule na položajima budućih usadaka. Na temelju rendgenskih nalaza određen je položaj i duljina usadaka. Prikazan je klasičan dvofazni kirurški protokol te operacijska tehnika s intraoralnim pretprotetskim šablonama. Uporabljeni su usadci Astratech microthread koničnoga profila kako bi se promjerom usatka što više približili promjeru budućega zuba. Dužina usatka određena je u skladu s navedenom radiološkom raščlambom tako da je usadak na poziciji 35 kraći od usadaka 34 i 37 zbog anatomske pozicije foramena mentale. Pri kirurškome pozicioniranju usatka osim pozicije koja je određena šablonom usadci su u okomitome smjeru pozicionirani u skladu s biološkom širinom sluznice i u konačnici parodontološko estetskim zahtjevima. Rezultati prikazuju uspješnost terapije nakon dobra planiranja i pripreme. Prikazana je prednost slojevite tomografije u planiranju i određivanju anatomsko-morfoloških karakteristika donje čeljusti koja nam daje sigurnost u izboru dužine, a osobito širine usatka. Predkirurško planiranje je postupak kojime možemo predvidjeti položaj usatka i estetiku budućega protetskog rada te tako olakšati kirurški zahvat.One of the fundamental pre-conditions for successful therapy by osseo-integrating implants is good pre-surgical planning. The aim of this work is to present the possibilities of radiographic and prosthetic evaluation prior to surgical treatment in the case of partial edentulousness.in the distal part of the mandibula. Diagnostic wax-up is done on a model of the jaw. After which a pattern is made of vacuum thermoplastic foil. Metal pellets of known diameter are placed in the positions of the waxed-up teeth to enable radiographic evaluation of the possibility of implantation in the planned positions. Classical orthopantomography is performed on the basis of which a multi-layer tomogram is done with exact cross-sections of the mandibula in the positions of future implants. On the basis of radiographic findings the position and length of the implants are determined. The classical two-phase surgical protocol is described and surgical technique with intraoral pre-prosthetic patterns. Astratech microthread implants of conical profile are used to ensure that the implant diameter is as close as possible to the diameter of the future tooth. The length of an implant is determined in accordance with the cited radiographic analysis, so that the implant in position 35 is shorter in relation to implants 34 and 37, due to the anatomic position of the foramen mentale. During surgical positioning of implants, apart from the position which is defined by the pattern, in the vertical direction the implants are positioned in accordance with the biological width of the mucous membrane and finally with periodontal aesthetic requirements. The results show the success of the therapy following good planning and preparation. The advantage is shown of multi-layer tomography in planning and determining the anatomical-morphological characteristics of the lower jaw, which provides assurance in the choice of length and particularly the width of the implant. Pre-surgical planning is a procedure by which it is possible to foresee the position of an implant and aesthetics of future prosthetic work, and thus to facilitate the surgical intervention

Therapy of Complete Edentulousness of the Lower Jaw with Fixed Bridges. Evaluation of Success for over a Period of 3 to 5 Years

Jedan od načina implantoprotetske terapije potpune bezubosti donje čeljusti jest izradba fiksnoga mosta na usadcima. Takva terapija predmijeva ugradnju 4 do 6 usadka u interforaminalno područje te izradbu mosta na usadcima. Takvi se mostovi češće fiksiraju vijcima, rjeđe cementiraju, a distalni privjesci su pravilo. Osnovni problem kod vijčano fiksirane suprastrukture jest pasivnost. S obzirom na tehnološki proces izradbe kovinske suprastrukture, termičke promjene nisu neuobičajene što rezultira pojavom napetosti prigodom fiksacije na usadke. Svaka napetost je štetna i u konačnici dovodi do mehaničkih komplikacija suprastrukture. Drugi problem su distalni privjesci. Opće je pravilo da dužina privjeska iznosi 2X, pri čemu je X okomita dužina (razmak) između zadnjeg i predzadnjeg usatka. To znači da privjesci mogu biti to duži što je bolji prostorni raspored usadaka. Drugi, manje važni problemi privjesaka tehničke su naravi i moguće ih je izbjeći pravilnim oblikovanjem suprastrukture. Prezentacija donosi procjenu uspješnosti terapi-je vijčano fiksiranim mostovima u donjim bezubim čeljustima. Razdoblje praćenja u rasponu je od 3 do 5 godina, s raščlambom komplikacija u istom vremenskom razmaku. Posebno se razmatraju mehaničke, a posebno biološke komplikacije. Analizirani su čestoća i karakter mehaničkih komplikacija. Rezultati istraživanja daju smjernice za sigurniji i uspješniji klinički rad s takvom vrstom protetske suprastrukture na usadcima.One of the methods of implantoprosthetic therapy of complete edentia/edentulousness of the lower jaw is the fabrication of a fixed bridge on implants. Such therapy assumes the placement of 4 to 6 implants in the interforamen area and construction of bridges on the implants. Such bridges are usually fixed with screws, rarely cemented, and distal cantilever are the rule. The basic problem in screwed fixed superstructures is passivity. Because of the technological process of constructing metal superstructures, thermal changes are not unusual, which results in the occurrence of tension when fixing on the implant. Any tension is harmful and finally leads to mechanical complications of the superstructure. Another problem is distal cantilever. As a general rule the length of the cantilever amounts to 2X, in which X represents the vertical length (space) between the last and the penultimate implant. This means that cantilever can be longer, which is better spatial arrangement of the implants. Other less important problems with cantilevers are of a technical nature and can be avoided by correct shaping of the superstructure. The presentation gives an evaluation of the success of therapy with screwed fixed bridges in the lower edentulous jaws. The period of monitoring ranges from 3 to 5 years, with analysis of complications in the same time period. Mechanical and biological complications are separately analysed. The frequency and character of mechanical complications are analysed. The results of the research provide guidelines for safer and more successful clinical work with such types of prosthetic superstructures on implants