Use of long implants with distal anchorage in the skull base for treatment of extreme maxillary atrophy : the remote bone anchorage concept

The objectives of this study are to present a new concept of the bone anchorage using long implants in remote bone sites and to discuss four cases treated with this method. Our patients were treated with long implants with a distant anchorage in the skull bone. The planning procedure, the construction of the drill guide, and the surgical protocol are described. In the clinical cases described, all four patients were rehabilitated with the remote bone anchorage concept using long implants anchored in the skull base. Patients were followed for 5 - 12 years and the implants remained present and stable in these time periods. The skull base implant is a new concept of bone anchorage using long implants. It can be a solution for complicated clinical situations (often failed bone reconstructions and implant placements) or an alternative for bone grafting and maxillary augmentation procedures. There is effective implant retention in the skull base, an anatomical area that is often overlooked for implant placement

Osteointegração nos amputados: um passo em frente!

ntrodução: Em Portugal, até agora, as próteses de reabilitação usadas para doentes amputados a nível transfemoral e transtibial condicionam trocas frequentes por motivos de alargamento, instabilidade, desconforto, problemas de pele e dor no coto que originam limitação funcional e perda de qualidade de vida. Em 1990, na Suécia, adoptou-se a técnica de osteointegração no membro inferior e superior com o desenvolvimento inovador da fixação óssea da prótese, eliminando o contacto com a pele e permitindo ganhar função e independência destes doentes. O desenvolvimento do protocolo OPRA permitiu definir critérios de indicação e seleção dos doentes e programar um processo de reabilitação individualizado. A técnica engloba 2 tempos cirúrgicos nos ossos longos. Os autores reportam o primeiro caso clínico de osteointegração realizado em Portugal. Caso Clínico: Um amputado transtibial com necessidade de trocas frequentes da prótese de reabilitação tipo socket, foi selecionado para osteointegração. Na fase S1 foi introduzido o implante intramedular. Após 6 meses, na fase S2 foi colocada a conexão de titânio por protusão à pele, e estabilização dos tecidos moles. O programa de reabilitação foi gradual e individualizado. Recorreu-se à escala visual analógica da dor para progressão da recuperação funcional. O doente está satisfeito e com capacidade de realizar eficazmente atividades até aqui inatingíveis. Discussão: A osteointegração implica uma equipa multidisciplinar e visa promover qualidade de vida e recuperar eficazmente doentes amputados para a sociedade ativa. Neste primeiro doente verificou-se ganho de função e independência com claro impacto psicosocioeconómico. Factores como a estrutura, dinâmica e bioquímica do tecido ósseo assim como a estabilização dos tecidos moles são fundamentais. As complicações possíveis incluem infeção, necrose cutânea, descelagem e fractura. As vantagens biomecânicas são maior segurança, suporte dos tecidos moles, estabilidade protésica e, no caso das amputações transfemorais, maior flexão do joelho. Conclusão: A osteointegração representa um passo em frente na reabilitação dos amputados e os autores acreditam que contribuirá no futuro para dotar as próteses de função sensitivomotora artificial, com o desenvolvimento das neurociências, robótica e engenharias electrotécnica e biomédica. A osteointegração permitiu projetar uma vida diferente e mais ativa para este doente, conjugando os impactos biomecânico, fisiológico, psicológico, social e económico

Effect of Long-Term Cycling Load for Abutment Screw Fixation in Implant Prosthodontics

The aim of this in vitro study was to use rotational tests on commercially available abutment screws to evaluate their potential for preload generation and to follow changes in torque by using newer fixation geometry on the interface of the implant-abutment screw joint. Five identical implant/abutment assemblies were chosen from each of the following systems: external hex with standard abutment and Replace with TorgTite screw (Nobel Biocare), Camlog universal abutment (Altatec Biotechnologies), DenTi internal hex (Dentimplant Ltd. Szentes, Hungary), straight abutment with internal antirotational element (Uniplant, Sinalisal, Budapest). Wax patterns of the upper premolar were performed and then cast from nickel-chrome alloy and full crown castings were cemented on abutments. In a test machine the magnitude and time of chewing function was predefined by using the desired force pattern. Each specimen was stressed for cycles equivalent to an intaoral load of 5 months or longer timescale. In the static test greater loss in torques was calculated for standard Branemark and Replace screw joints. Assuming that the optimum proportion is the same when we calculate loosening versus tightening torque we obtained a decrease between 0.70-0.59 for Replace and Branemark abutments and a more moderate loss of between 0.90-0.84 for the other systems investigated. The ten month equivalent cycling test produced a loosening torque of 16-17 Ncm for Branemark and Replace abutments. Similar decrease in torque was not found for the other three systems. It was concluded that different approach in achievement of necessary mechanical integration can be seen in implant systems, although a reliable loosening torque could be measured after a longer time scale

Effect of Long-Term Cycling Load for Abutment Screw Fixation in Implant Prosthodontics

The aim of this in vitro study was to use rotational tests on commercially available abutment screws to evaluate their potential for preload generation and to follow changes in torque by using newer fixation geometry on the interface of the implant-abutment screw joint. Five identical implant/abutment assemblies were chosen from each of the following systems: external hex with standard abutment and Replace with TorgTite screw (Nobel Biocare), Camlog universal abutment (Altatec Biotechnologies), DenTi internal hex (Dentimplant Ltd. Szentes, Hungary), straight abutment with internal antirotational element (Uniplant, Sinalisal, Budapest). Wax patterns of the upper premolar were performed and then cast from nickel-chrome alloy and full crown castings were cemented on abutments. In a test machine the magnitude and time of chewing function was predefined by using the desired force pattern. Each specimen was stressed for cycles equivalent to an intaoral load of 5 months or longer timescale. In the static test greater loss in torques was calculated for standard Branemark and Replace screw joints. Assuming that the optimum proportion is the same when we calculate loosening versus tightening torque we obtained a decrease between 0.70-0.59 for Replace and Branemark abutments and a more moderate loss of between 0.90-0.84 for the other systems investigated. The ten month equivalent cycling test produced a loosening torque of 16-17 Ncm for Branemark and Replace abutments. Similar decrease in torque was not found for the other three systems. It was concluded that different approach in achievement of necessary mechanical integration can be seen in implant systems, although a reliable loosening torque could be measured after a longer time scale

Dental Implant Treatment for a Patient with Bilateral Cleft Lip and Palate

Dental reconstruction in the cleft space is difficult in some patients with cleft lip and palate because of oronasal fistulas. Most of these patients receive a particle cancellous bone marrow (PCBM) graft to close the alveolar cleft, and secondary bone grafting is also required. Treatment options for the alveolar cleft including fixed or removable prostheses require the preparation of healthy teeth and are associated with functional or social difficulties. Recently, the effectiveness of dental implant treatment for cleft lip and palate patients has been reported. However, there have been few reports on the use of this treatment in bilateral cleft lip and palate patients. We report the case of a patient who had bilateral cleft lip and palate and was missing both lateral incisors. She received dental implant treatment after a PCBM graft and ramus bone onlay grafting (RBOG). A 34-month postoperative course was uneventful.</p

Numerical and Experimental Analysis of the Influence of Assembling Conditions and the Tolerance of Adapted Implantological Components on the Durability of the Prosthetic Construction

Durable fastening of implant retained prosthetic restorations, consisting of a series of elements, is one of the main factors of successful prosthetic rehabilitation. Clinically observed mechanical problems concerning the above mentioned components are complications that occur most often in the loading phase. The aim of this research was evaluation of the suppleness of the implant- -anti-rotary abutment construction to loosening under the influence of labile mechanical stress. Numerical analysis of resistance based on the finite element analysis (FEA) was used in the initial phase of this research. The actual tests were done with the use of a dynamic mechanical analyser Netzsch DMA 242 and a polarisation microscope equipped with a CCD camera. A series of implants connected with abutments composed of two parts were analysed. The results of initial studies utilizing the finite element analysis (FEA) allowed definition of the spheres of stress concentration. On the basis of in vitro experiments, the investigators evaluated the influence of tolerance of adapted implant-abutment interface fit, as well as the torque used in the assembly of the abutment, on the occurrence of micromovements and loosening of components. The results strongly indicate correlation between the chosen variables and the risk of occurrence of mechanical complications

The development of a component to improve the loading safety of bone-anchored prostheses

Use of socket prostheses Currently, for individuals with limb loss, the conventional method of attaching a prosthetic limb relies on a socket that fits over the residual limb. However, there are a number of issues concerning the use of a socket (e.g., blisters, irritation, and discomfort) that result in dissatisfaction with socket prostheses, and these lead ultimately a significant decrease in quality of life. Bone-anchored prosthesis Alternatively, the concept of attaching artificial limbs directly to the skeletal system has been developed (bone anchored prostheses), as it alleviates many of the issues surrounding the conventional socket interface.Bone anchored prostheses rely on two critical components: the implant, and the percutaneous abutment or adapter, which forms the connection for the external prosthetic system (Figure 1). To date, an implant that screws into the long bone of the residual limb has been the most common intervention. However, more recently, press-fit implants have been introduced and their use is increasing. Several other devices are currently at various stages of development, particularly in Europe and the United States. Benefits of bone-anchored prostheses Several key studies have demonstrated that bone-anchored prostheses have major clinical benefits when compared to socket prostheses (e.g., quality of life, prosthetic use, body image, hip range of motion, sitting comfort, ease of donning and doffing, osseoperception (proprioception), walking ability) and acceptable safety, in terms of implant stability and infection. Additionally, this method of attachment allows amputees to participate in a wide range of daily activities for a substantially longer duration. Overall, the system has demonstrated a significant enhancement to quality of life. Challenges of direct skeletal attachment However, due to the direct skeletal attachment, serious injury and damage can occur through excessive loading events such as during a fall (e.g., component damage, peri-prosthetic fracture, hip dislocation, and femoral head fracture). These incidents are costly (e.g., replacement of components) and could require further surgical interventions. Currently, these risks are limiting the acceptance of bone-anchored technology and the substantial improvement to quality of life that this treatment offers. An in-depth investigation into these risks highlighted a clear need to re-design and improve the componentry in the system (Figure 2), to improve the overall safety during excessive loading events. Aim and purposes The ultimate aim of this doctoral research is to improve the loading safety of bone-anchored prostheses, to reduce the incidence of injury and damage through the design of load restricting components, enabling individuals fitted with the system to partake in everyday activities, with increased security and self-assurance. The safety component will be designed to release or ‘fail’ external to the limb, in a way that protects the internal bone-implant interface, thus removing the need for restorative surgery and potential damage to the bone. This requires detailed knowledge of the loads typically experienced by the limb and an understanding of potential overload situations that might occur. Hence, a comprehensive review of the loading literature surrounding bone anchored prostheses will be conducted as part of this project, with the potential for additional experimental studies of the loads during normal activities to fill in gaps in the literature. This information will be pivotal in determining the specifications for the properties of the safety component, and the bone-implant system. The project will follow the Stanford Biodesign process for the development of the safety component

Direct measurement of prosthetic loading for evidence-based practice

The demand for an evidence-based clinical practice involving lower limb amputees is increasing. Some of the critical care decisions are related to the loading applied on the residuum partially responsible for comfort and functional outcome. This loading can be assessed using inverse dynamics equations. Typically, this method requires a gait laboratory (e.g., 3D motion analysis system, force-plates). It is mainly suited for the analysis only few steps of walking while being expensive and labour intensive. However, recent scientific and industrial developments demonstrated that discrete and light portable sensors can be placed within the prosthesis to measure accurately the loading during an unlimited number of steps and activities of daily living. Several studies indicated that method based on direct measurements might provide more realistic results. Furthermore, it is a user-friendly method more accessible to clinicians, such as prosthetists. The purpose of this symposium will be to give an overview of these additional opportunities for clinicians to obtain relevant data for evidence-based practice. The three main aims will be: • To present some of the equipment used for direct measurements, • To propose ways to analyse some key data sets, • To give some practical example of data sets for transtibial and transfemoral amputees

Static Load Bearing During Early Rehabilitation Of Transfemoral Amputees Using Osseointegrated Fixation

Many transfemoral amputees wearing conventional socket prostheses experience pain related to the socket-residuum interface and difficulties with socket retention or fit due to a short residuum. In consideration of these problems a direct skeletal fixation method has been developed whereby a titanium implant is screwed into the medullary canal of the residual femur. Prosthetic components are directly attached to the fixation, once osseointegrated, removing the need for a prosthetic socket. The rehabilitation program to return to ambulation involves incremental static loading of the fixation until full weight bearing is achieved. The rate of loading, which is intended to be isolated to the long axis of the fixation, is determined by the quality of the residual skeleton and a qualitative assessment of the pain experienced by the amputee on loading. Rotational loading of the implant is to be avoided at this stage. The amputee uses a domestic weigh-scale to provide feedback of the load applied. This study aims to measure the true load applied to the fixation and compare this with the clinically prescribed axial load