Oral implantology :: The Beginning - Part II

I would like to bring to your attention a clinical report, with which I attended the First Anniversary Scientific and Practical Conference of TNTM, on the occasion of the 1300th anniversary of the founding of the Bulgarian state in 1981 in Stara Zagora. The clinical case described and illustrated in this report was in fact the actual beginning, set in 1978. Up to this point, I was aware of sporadic implant case (Dr. Dzhelepov in 1947) of a subperiosteal implant. The case described and all thereafter were the FIRST attempt at systematic occupation in this delicate area of ​​its time, an area that is too big a problem, even today in dentistry. From today's point of view, both the report and the then methods and some principles and some conclusions seem too naive, even incorrect, but it seems to me that it would be appropriate to give due consideration and respect to this work and to evaluate it by dignity, of the relics that speak of the people who created them, of their courage, of their anxieties, of sleepless nights, of adversity, of responsibility, of malice and envy, of meanness and vulgarity, of dishonesty, but also of joy of the results, for the story, for the TRUTH ...

ENOSAL IMPLANTOLOGY IN THE ORAL CAVITY - SURGICAL AND PROSTHETIC ASPECTS
THE ONE CLINICAL CASE – DEMONSTRATION
REGIONAL HOSPITAL - SLIVEN
NEUROSURGICAL DEPARTMENT
Dr. Hristo Mitev Hristov

Introduction and overview of the problem

The question of prosthetics for young individuals with total loss of teeth and with distally unlimited defects of the dental rows has been and remains open as a problem in dentistry, despite the variety of methods available.
In many countries around the world, like GDR is a top priority, the dentists put subperiosteal and enosal implants and bridge prosthetics  as moving prostheses are not well received by patients.

The problem has two aspects at all: surgical and prosthetic.

For implantologists, the most important problem is incorporating the implant into the bone and extending the time from incorporation to eliminating the "foreign body", which they achieve through in-depth study of medical indications and counter indications, as well as knowledge about the operational risks and short stays of enosal implants.

After implantation, the human body very rarely responds immediately with the discard of the implant. The mistakes made only come after the functional load.

For patients, the most important moment of implantation is the placement on the implant and the other teeth of the supra structure. But the implantologist knows that the physiognomic effect is not the most significant one. It is more important to get a functional result from the surgery. Therefore, supra construction should only be undertaken when establishing the optimal functional stability of the implant, corresponding to that of the other teeth.
The chemical and enzymatic action of the saliva is taken into account when selecting the implant material. Along with plastics and ceramics, metals have been of particular importance for many years. After numerous experimental and clinical studies, the dental alloys used so far have been criticized as unsuccessful. Absolute corrosion resistance cannot be guaranteed for all alloys, since potential conditions for potential differences are created in the electrolyte environment in the oral cavity. The best tolerance is given to the pure metals, and of the latter, the most optimal corrosion resistance and lack of reactivity to the surrounding tissues are the metals Titanium and Tantalum.
Due to the fact that Titanium is completely inert, it does not matter further than what material the superstructure will be made of. For example, titanium abutments can be coated with any noble alloy without developing electrolytic processes that have a negative effect on the operation. There are authors, however, who use noble steels of chromium, cobalt and molybdenum for implants (Muller 1978).
Almost all use implants with form of „anchor“ but no prefere implants with form of root of tooth because of the risk of penetration into the maxillary sinus.
Anchor-shaped implants are very bulky and require a lot of bone to implant, and dental-root implants have insufficient attachment capabilities.
All authors implant the implants in a vertical direction, thus creating a bone defect coinciding with the mucosal incision.

A man in excellent physical and mental health. Dental status- Available roots of 13, 11, 21 and 23 teeth of the upper jaw and roots of 33, 32, 31, 41 42 and 43 teeth. He had partial dentures with hooks that he could not wear and no longer wanted. She has been eating liquid - porridge food for several years. Diagnosis: Adentio partialis superior et inferior. Radices gangraenosae 33,32,31,41,42,43,13,11,21,23. Pro causa protetica.



Technique of the proposed operation. Implant manufacturing technique and technology.

By an incision of the mucosa along the alveolar ridge and one or two divergent incisions in the direction of vestibulum oris, we detach the mucoperiost, and then we prepare a special bed in the bone where we incorporate the implant.

Here is the operation itself schematically in the following figures:

The operation "live":

I show own implant form (Figures 13, 14, 15 and 16). We make the design of the implant from profile waxes for the Ney - system then do cast in a cassette machine. We polish very well in the cervix of the implant and the rest of the implant we put under sandblasting. All this we do in the dental laboratory / From Fig.13 to Fig.16 - The implant shape /


We do the implants for the specific case by measuring the distances to canalis mandibularis and sinus maxillaris by pre-X-ray. We use "Kuncher" pins as material. The finished implant we sterilize by boiling.
We make the bone bed so that the implant is difficult to enter. The non-implanted portion of the bone bed we fill with lyophilized spongiosis and then we suture. The stiches we remove on the 5th - 6th postoperative day.
 We file down the teeth, take an imprint with Dentaflex - solid and paste, and make a bridge of the same material so that there are no potential differences.




Design principles

During the operative plan, it is imperative to plan the final prosthesis using models and X-rays, since the number and placement of implants depends on the type of prosthetic structure.
1. The implant should only be loaded vertically.
Horizontal forces result in rapid shaking of the implant.
2. The implant should be inserted into a block with at least 2 teeth of its own.
Each natural tooth with a healthy periodontium has its own mobility that is missing from the enosal implant. In order to avoid "sinking" of the implant, it must be connected with healthy teeth / G. Otto, H. Hampel, O. Krause /.
3. Limited distance of the implant from the natural teeth. According to Otto, Hampel, Krause, this distance should not exceed 2 premolar widths.

/ From Fig.19 to Fig.22 - principles of implant prosthetics together with natural teeth by Otto, Hampel und Krause /

 

4. Optimal articulation ratios.
We model the chewing surfaces of the intermediate elements with some reduction. In addition, they must be modeled flat to prevent horizontally acting forces.

5. Of great importance is the stump of the implant. The crown on it should lie so that it does not allow plaque to accumulate on the neck of the implant, leading to the formation of pockets, niches and inflammatory processes.

Almost all implantologists put a temporary bridge in order to immobilize the implant. The time for its first functional load is different according to different authors. Some, however, believe that a long unloaded implant produces the same clinical results as an immediate one. They take definitive prosthetics no earlier than 6 weeks.

Casuistry and case analysis

In the department we operated and prosthetized 4 cases, which we followed clinically and radiographically 1 year. and 7 m., 1 year and 5 m., 6 m. and 4 m. By sex - 2 women and two men. Patients' age was from 30 to 45 years. Three of the cases had a distal unlimited defect of the lower jaw on the left, and one with preserved roots of the front teeth. The surgeries we made by their own methods, implants and bridges were made with their own shape and with their own technology. We observe the generally valid principles. Observations showed, however, that by one of the implants, which had not been prosthetized and loaded by week 5, developed an inflammatory process and shook. He was the only one, which we removed recently due to eating pains.
The rest of the cases we prosthetized no later than week 3 and as soon as the bridges were placed, the patients began to feed.

We warned all patients to observe absolute oral hygiene. Implants and bridge prostheses we subjected to a corrosion test, which did not exceed 8 mV.

Conclude
Given the nearly 2 years of experience, although poor, we can draw the following conclusions:
1. Implant fabrication material need not be Titanium or Tantalum. The alloy of „Kuncher“nails, which is actually a noble steel, is satisfying. However, it is necessary to have uniformity in the implant material and the supra construction.
2.    We believe that the operative technique is better than the one known so far for two reasons:
- We take a significantly smaller amount of bone tissue when incorporating the implant.  The shape of the implant allows for different variations, which in turn allows us to implant on the upper jaw - something that we not found in the available literature.
- We believe that there is no need for a temporary bridge, but rather a definitive one - because we put the implant closely into the bone bed, so that immediately after surgery it is stable enough for prosthetics. Only the thread removal period is waiting.

3. We do not have to wait long from surgery until the prosthesis, because unless we place the bridge on the implant, the patient cannot chew. The accumulated plaque, even tartar, cause an inflammatory process with an unfavorable result.
4. Surgical and dental Mechanical technology are easy and every dentist and dental Mechanic at a county health can learn.
5. As a final conclusion - we can put the method into the practice as a method of choice for prosthetic of cases with distal unlimited defect and total toothless in young individs.

Contact pfhristov@yahoo.com for more details
 

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