Relative Indications and Contraindications for Bone Grafting - Dissertation Example

 Relative Indications and Contraindications for Bone Grafting Reconstructing the defects in the anterior part of the maxilla to allow implant to occur is a daunting task. However, one procedure that is being used by dental surgeons is the usage of autogenous platelet gel. Using an autogenous platelet gel can play a role in the better healing of bone grafts. A particulated autogenous bone, platelet gel and a titanium mesh can be used for alveolar bone reconstruction of the anterior maxilla before implant placement occurs. In a study conducted on the reconstruction of anterior maxilla with platelet gel, autogenous bone and titanium mesh, a patient with severe resorption of anterior maxilla was implanted with the reconstruction material. Corticocancellous bone from the iliac crest and the autogenous platelet gel were blended together. The mixture was fixed against a titanium mesh, which was attached to the bone of the palate. After a period of 4.5 months, titanium implants replaced the mesh and after another eight months, healing abutments were introduced and a fixed dental bridge was made. The results of the experiment showed that the implants became part of the bone structure and the graft remained intact for over three years. The experiment concluded that using particulated autogenous bone and platelet gel can be effective in resorbed anterior maxilla. It was also suggested that the autogenous growth factors in the gel were part of the reason why the technique was successful (Thor). Osseotite implants can also be employed in resorbed anterior maxilla. However, it has been seen that the success of endosseous implants is hindered by narrow alveolar ridges. These ridges can be widened by cutting the alveolar bone in the logitudanal direction and the bone gap could then be covered by collagenised pig bone. The osseotite implants could then be put in immediately. The implants can then be plastered by a mixture of autogenous tuberosity and collagenised pig bone. The benefits of this technique for patients include less incisions and trauma due to the surgery. The procedure is also relatively less time consuming (Guirado, Zamora and Yuguero). The usage of zygomatic implants is also a surgical intervention used as a treatment option for bone loss in the maxillae. Studies have shown that zygomatic bone is suitable for implants. Using such implants has benefits like being an alternative to bone grafts and reduced morbidity. Zygomatic bone is a preferable option for extreme resorption in the maxillary region. Zygomatic implants are done in the posterior region along with implants in the anterior region successfully. Contraindications of implants in the anterior maxillary region include respiratory problems. Patients may develop infections of the upper respiratory tract; this might result in the closure of the maxillary ostium, ultimately culminating in sinusitis. If this happens, there are chances that the sinusitis becomes chronic and necessitates the need to re-establish ventilation to the sinuses. Moreover, it has been seen that there in increased incidence of inflammatory reactions in the normal nasal and maxillary mucosa in the areas where titanium implants traverse the mucosa (Gil, Diago, Martínez, and Bowen). Mandibular bone grafting can also be done for patients with resorbed bone in the anterior maxilla. In a study for single tooth implants for anterior maxilla, the results indicated that bone graft method is suitable for people with a narrow alveolar ridge; however the resorption of the graft was very large (Widmark, Andersson, and Ivanoff). Buccal onlay bone grafting is also done in the anterior maxilla in usual dental implants. Loss of alveolar bone in the anterior maxilla may cause obstacles for bone implants or make it difficult for positioning. This may mitigate the end aesthetic outcome for restoration. Bone augmentation can take place; however a contraindication is that it has an affect on osseointegration. Mandibular block onlay grafts are an option for augmenting the width of the anterior maxilla before implant placement (Artzi, Parson, and Nemcovsky). Osseodistraction is a relatively new technique that is used in implantology. The technique entails growing bone and soft tissue in the vertical direction and using a method like osteotomy. In the osteotomy method, the bone is separated from the bone plate in order to increase it is length. The indication of the method, as Dr. Krupp observes, is that it can be used to place the bone where needed. This enables patients to become eligible for implants. The technique is easy top carry out and allows the dentists and surgeons to predict what the aesthetic result of the procedure would be (Seckman). The indications and the benefits of osseodistraction can be assessed from a study conducted on dental implant stability. The objective of the study was to find out the implant stability in osseodistraction-generated (ODG) bone after a consolidation period of two months. The conclusions of the study stated that the OD bone provided high primary and secondary stabilities after implant placement (Bilbao, Oliveira, Varela-Centelles, and Seoane). A procedure used in severely atrophic edentulous patients, four different types of grafts can be made use of. Tilted implants are used where the bone loss is not extreme and can relieve the patient from undergoing sinus grafting. The indications of this method require the use of long zygomatic implants in order to stabilize a region that is not near to the alveolus. Onlay grafts can be used in areas where the bone loss has been very severe. Bone is taken from extra-oral areas. Iliac and calvarial grafts can be used. However, in a study conducted, calvarial grafts proved to be more long-lasting than iliac grafts and the research supported the usage of calvarial grafts before implantation. However, the contraindication of this method is that it can not be used if the bone resorption has occurred to such a degree such that onlay grafts can not set right the skeletal discrepancy between the jaws. In such a case, a Le Fort 1 down-fracture can be used. However, this needs to be done in conjugation with inlay grafting to the inner side and onlay grafting to the outer side of the down-fractured parts. However, the volume of bone that is needed for this procedure can only be derived from ilium; the implants need to be introduced after four months. When all bone has been resorbed, and no bony structure remains to attach grafts onto, a vascularized free-flap is used (Schaeffer). In another research study, the reconstruction of severely atrophic maxilla was done using a combination of sinus augmentation, onlay bone grafting and implants. Bilateral sinus floor elevation was juxtaposed with cancellous bone graft with buccal and labial onlay graft; L-shaped corticocancellous blocks were utilized from the posterior iliac crest. The results of the study showed that this surgical intervention can be suitable for reconstruction of the maxilla (Neyt, Clercg, Abeloos, and Mommaerts). Assignment 2 “CT guided surgery is the future of implant surgery”. With reference to the literature discuss the evidence base for the use of CT guided implant surgery and discuss the relative merits of traditional versus CT guided surgery. Dental implants are devised and carried out by surgeons drawing upon both findings from the dental x-rays and clinical judgment. These x-rays can be of great help but they offer only a two-dimensional view of the inner structures. Existing two-dimensional implant surgery techniques have certain drawbacks. Although they allow surgeons to estimate the bone height with relative precision, the techniques often fall short in finding out the bone width. Inadequate width presented implications for the correct placement of the implant. Moreover, it is increasingly difficult to locate nerves and other important structures. As a result, two companies took the initiative to solve the problem of finding out the dimensions of jaw bone structures. Computer Tomography (CT) scans have helped to determine which structures can be most suitable for successful implants. This helped to identify the sites which had the most predictability and resulted in an “implant system” which met the reconstructive requirements of the patient. Three dimensional imaging slicing emerged has an alternative to conventional two-dimensional radiography. This allows surgeons to take cross-sectional images of the structures; the technique is quickly becoming an effective and accurate mode of viewing the structures in the jaw. CT scans can enable surgeons to know the structures in great detail. Surgeons can plan their surgeries better; the knowledge also helps them avoid any unexpected surprises that they might come across with in the procedure. The biggest advantage that CT scans offer to surgeons is that they allow surgeons to place implants with a level of accuracy that could not be achieved earlier. Moreover, the surgical procedures, as guided by CT scans, can be performed in rather the same way as conservative procedures and offer benefits such as minimal discomfort, less time-consuming and a more predictable result (Dental Health Directory). Computer guided dental implant surgery is a huge leap in the replacement of teeth with dental implants. CT scans and 3-D imaging are used to place dental implants in the prescribed sites with accuracy. The three-dimensional visualization of the structures save the surgeons from a lot of estimation and speculation in what sites of the jaw can prove to be the best site for implant. Computer guided implant surgery substantially makes the dental implant process easier and gives rise to much greater patient satisfaction. The two systems available in the market are SimPLant and Nobel Biocare. However it needs to be noted that the applications and technology are expensive and have compatibility issues. On the other hand, with advances in technology, competition is rising. This will help to bring down the costs of the systems and establish them as a more convenient and cost-effective option for dental implants. An oral surgeon observes that, “Guided surgery helps us practice restoratively driven implant dentistry. Model Based and CT based guided surgery is here. If you don’t consider it in your work up you may be outdated” (Minzenmayer). Guided implant surgery has many advantages. The experiences of many dentists are attestation to them. Not laying a flap produces less complications and side-effects. Also, recovery is prompt and post-operative pain is less. Moreover, the trauma that hard and soft tissue sustains in the surgery is also reduced to a minimal using guided surgery. CT scanning equips the surgeon with the required knowledge to perform the procedure and to find the safest location for placing the implant in advance of the surgery. The majority of the work is performed outside the domain of the office. Before performing the procedure, when it is being planned, the CT scan is fed into computer programs. These programs can then find the safest sites for the implant. Moreover the system enables the sharing of information of the computer-generated findings of potential implant sites with the dentist so that the treatment provided is effective. Later on, a surgical guide is made. An example of a procedure that uses 3-D CT scanning techniques is the Teeth-In-An-Hour. This procedure allows the implantation of teeth in the patients in less than an hour. A single process is needed. The doctor and the surgeon work together in concert in order to channel their knowledge into providing a safer and more precise implant surgery. The final prosthesis is completed before the commencement of the surgery. The arthroscopic way by which computer-guided implant surgery is performed does not necessitate the usage of flaps and causes lesser bruising. The patients are also able to go back to their routine the very next day. A CT scan of the jaw bone is captured and a three-dimensional model of the interior structures is then created. The software finds the sites for the implant (Palm Beach Center for Periodontics & Implant Dentistry). Many studies have been conducted that have served to evaluate CT guided implant surgery. In one such research, the reliability of implant placement after the virtual planning of implant sites was assessed and cone-beam CT data and surgical guide templates were made use of for finding out the implant sites. The experiment concluded that implant placement for finding out the positions of the implants using three-dimensional images proved to be reliable in evaluating the implant dimensions, location, and anatomical complications before the operation; using CT scans and three-dimensional images also proved to be a feasible option for flapless surgery (Nickenig and Eitner). In another research the accuracy of the CT-guided template-assisted implant placement system was determined. The results of the study concluded that computer-assisted implant planning and insertion offer good precision. Any errors that occurred in the results were due to the system and reproducibility errors (Horwitz, Zuabi, and Machtei). Implant treatment puts emphasis on the reduction of the time spent for treatment and the complications of the procedure. Three-dimensional imaging offers the advantage of developing computer-generated options for potential implant sites. CT scanning and integrated software can allow placements to occur using surgical guides or optical tracking systems. Since surgical guides are easily available, they are preferred in private setups. It has been predicted that advances in three-dimensional imaging in guided surgery will significantly reduce the typical laboratory-technician work and will incorporate the fabrication of superstructures with virtual treatment planning from the initiation of the planning process (Jorg et al.). Given the positive results of the researches conducted on CT guided implant surgery, it can be predicted that CT guided implant surgery does have a scope in the future as a popular mode for performing implants. The advantages of the procedure and the greater knowledge that it equips the surgeons with is an example of the fact that the practice of dentists and surgeons would be outdated if they fail to incorporate the methods in their surgeries. Traditional surgery can be preferred since it does not use expensive software. The cost of operating are reduced in traditional surgery and it is more suited for novice practitioners. While novice practitioners are discouraged from performing the surgery using three-dimensional imaging and related software, the success rate and positive outcomes of the method in surgeries of experienced practitioners reflects the importance and preference of the procedure over conventional surgery. Assignment 3 Develop a care pathway for patients who may require multidisciplinary care. In surgeries and complicated medical conditions, different organs can get involved. This mandates the collaboration of professionals belonging to different professions. Such procedures are best managed when people from various fields come together to share their knowledge and expertise and to work together in devising a treatment plant that works best for the patient. It is the duty of each member to share his or her skills and knowledge with other members of the interprofessional team. In return, the patient is benefited from “joint best practice” (Evans, Montgomery, and Gullane 526). In implant procedures, a multi-disciplinary team needs to be put together. This includes the dentist who is coordinating the treatment and the restorative dentist. Moreover, a prosthodontist may also be called for to perform the procedure. A prosthodontist will be the key figure in dental implant procedure. An oral surgeon will be needed to place the implant in to the potential site surgically. The services of prosthodontist will also be required in the procedure since periodontists specialize in dental implants for teeth replacement. If the patient is a young child, a pediatric dentist also needs to be part of the team. Patients who have suffered orofacial trauma may also need to have a multi-disciplinary team in order to provide a comprehensive treatment. The treatment can not only involve dental implants but also maxillofacial procedures. This requires the expertise of people belonging to orthodontics and maxillofacial surgery. Oral and maxillofacial surgeons would be needed to use dental implants to fill in the gaps of missing teeth. The team would also be able to remake the bone in areas where bone is not adequate for implants. Since orofacial trauma can misalign the teeth, gingivial gum tissue can be remodeled in areas around the implant so that the aesthetic appearance of the implant can be increased. If facial trauma occurs, the doctors need to respond promptly. Facial lacerations, fractured bones and intra-oral lacerations could be some of the features of a patient with facial trauma. Therefore, not only the bones and the fractured jaw needs to be realigned, and implants placed in the regions where teeth are absent, but the nerve supply also needs to be restored along with fixing the dislocated facial bones back into place. If there is orofacial pain, the relevant doctors need to be called on for treating the patient. The classes of orofacial pain include acute dental, neurovascular, musculoskeletal and neuropathic (Sharav and Benoliel 1). Thus, neurologists may also be part of the team. Prosthodontist For treating gum recessions via grafting and dental implants Restorative dentist For normal dental procedures Coordinating dentist For coordinating the treatment plan Oral surgeon For aligning teeth Prosthodontist Dental implants and reconstructive surgery Maxillofacial surgeons Dental implant placement Neurologists Connecting the nerve supply; managing pain Works Cited Bilbao, Arturo, M. Hernandez-De Oliveira, Pablo I. Varela-Centelles, and J. Seoane. “Assessment of dental implant stability in osseodistraction-generated bone: a resonance frequency analysis.” Clinical Oral Implants Research 20.8 (2009): n. pag. Web. 13 July 2010. Dental Health Directory. Computer Guided Implants Surgery. DentMedHost, 2010. Web. 13 July 2010. Evans, P. H. Rhys, Paul Q. Montgomery and Patrick J. Gullane. Principles and practice of head and neck oncology. Informa Health Care, 2003. Print. McCarthy, Caroline, Raj R. Patel, Philip F. Wragg and Ian M. Brook. “Dental Implants and Onlay Bone Grafts in the Anterior Maxilla: Analysis of Clinical Outcome” The International Journal of ORAL & MAXILLOFACIAL IMPLANTS 18 (2003): 242-249. Web. 3 July 2010. Gil, Sonica Galán, Miguel Peñarrocha Diago, Jose Balaguer Martínez, and Eva Marti Bowen. “Rehabilitation of severely resorbed maxillae with zygomatic implants: An update.” Medicina Oral, Patología Oral y Cirugía Bucal 12.3 (2007): n. pag. Web. 13 July 2010. Guirado, Jose Luis Calvo, Guillermo Pardo Zamora, and Maria Rosario Saez Yuguero. “Ridge splitting technique in atrophic anterior maxilla with immediate implants, bone regeneration and immediate temporisation: a case report.” Journal of the Irish Dental Association 53 (2007): 187-190. Web. 13 July 2010. Horwitz, Jacob, Otman Zuabi and Eli E. Machtei. “Accuracy of a computerized tomography-guided template-assisted implant placement system: an in vitro study.” Clinical Oral Implants Research 20.10 (2009): 1156-1162. Web. 13 July 2010. Jörg, Neugebauer, et al. “Computer-aided manufacturing technologies for guided implant placement.” Expert Review of Medical Devices 7.1 (2010): 113-129. Web. 13 July 2010. Minzenmayer, Greg. Guided Implant Surgery: The Future? OsseoNews, Inc., 2010. Web. 13 July 2010. Neyt, Luc F, Calix A.S de Clercg, Johan V. S. Abeloos, and Maurice Y. Mommaerts. “Reconstruction of the severely resorbed maxilla with a combination of sinus augmentation, onlay bone grafting, and implants.” Journal of Oral and Maxillofacial Surgery 55.12 (1997): 1397-1401. Web. 13 July 2010. Nickenig, Hans-Joachim and Stephan Eitner. “Reliability of implant placement after virtual planning of implant positions using cone beam CT data and surgical (guide) templates.” Journal of Cranio-Maxillofacial Surgery 35.4 (2007): 207-211. Web. 13 July 2010. Palm Beach Center for Periodontics & Implant Dentistry. CT Guided Implant Surgery. PBHS Inc., 2008. Web. 13 July 2010. Schaeffer, Bill. Implant therapy in severely atrophic edentulous patients. ADi Newsletter, 2009. Web. 13 July 2010. Seckman, Cathy Hester. Dental Implants. PennWell Corporation, 2001. Web. 13 July 2010. Sharav, Yair, and Rafael Benoliel. Orofacial pain and headache. Elsevier Health Sciences, 2008. Print. Thor, Andreas. “Reconstruction of the Anterior Maxilla with Platelet Gel, Autogenous Bone, and Titanium Mesh: A Case Report.” Clinical Implant Dentistry and Related Research 4.3 (2006): n. pag. Web. 13 July 2010. Widmark, G., B. Andersson and C.-J. Ivanoff. “Mandibular bone graft in the anterior maxilla for single-tooth implants: Presentation of a surgical method.” International Journal of Oral and Maxillofacial Surgery 26.2 (1997): 106-109. Web. 13 July 2010. Read More