Clinical Application of the gentle.distract System

Transcription

1 Patented: Seitingen-Oberfl acht, Germany Tel.: +49 (0) / Fax: +49 (0) / info@zepf-dental.com

2 In dental implantology, procedures for the distraction of atrophic bone were developed, allowing an augmentation of the alveolar ridge. Distraction osteogenesis thus offers better conditions for a posterior insertion of implants. In order to reach this target, distractors were developed in dental surgery in co-operation with specialized manufacturers. These distractors are used successfully for some time already. Osteodistraction in dental implantology requires detailed clinical diagnostics and a strict clinical indication. In order to keep the complication level as low as possible, appropriate operative skills are required. The surgeon, the prosthodontist and the dental laboratory have to co-operate closely. In many cases, osteodistraction with the Distractor can be used as an alternative to bone transplantation. Indications Unilateral and bilateral free-end situations in the mandibula (premolar and molar region) Distraction of bone segments in the front region of the maxilla and the mandibula Distraction of small bone segments in the case of single tooth loss in the maxilla and the mandibula Distraction of bone segments in the interforaminal region of the toothless mandibula Distraction of bone segments in the toothless front region of the maxilla Case 1: Front teeth loss 1/1, 2/1 & 2/2 Case 1: Drilling template inserted with positioning sleeves Case 1: Laboratory model with dental prosthesis and inserted distraction screws Case 1: Distractors in 2 separated bone blocks in the front region of the maxilla

3 Advantages of the Advantages of the Distraction Autologous bone is augmented in situ Soft tissue and periosteum are also growing, thus offering better conditions for the implantation, notably optimal esthetic results The use of alloplastic augmentation materials can be avoided to a large extent Better conditions for a posterior implant insertion, as only a low bone resorption will occur, compared to bone transplantation Less wound healing defi cit compared to artifi cial bone blocks More gentle than bone transplantation as there are no two operation areas, the risk of infections is reduced Lower risk of jaw fracture (No bone block has to be removed from the jaw) Better long-term prognosis for implants as the relation between implant length and crown length is balanced Disadvantages of Previous Systems Hygienically critical areas In the front region most remedies are esthetically unsatisfactory in the phase of distraction, thus restricting the life comfort of the patient The distraction vector is sometimes diffi cult to secure; tilting of the bone segment Advantages of The temporary distraction bridge allows an esthetical patient-centered care during the phase of distraction; especially in the maxilla an esthetically appealing remedy is achieved Soft tissues and periosteum are also growing The distraction vector can be predetermined. (projectable and defi nable) The distraction bridge in the lateral tooth area stabilizes the occlusion and masticatory function and secures the coordination of the tongue and masticatory muscles The distractor is concealed under the temporary distraction bridge Case 2: Tooth loss in the left side of the mandibula, with bone deficit Case 2: Inserted Distractor in the bone block

4 Case 3: Front teeth loss 2/1 & 2/2 Case 3: Plaster model with dental prosthesis and distraction screw Equipment and Instrumentation and Distractors by Surgical motor for implantology, with salt cooling Oscillating saw or piezo device Disc-protected diamond discs Bone Splitting System by Surgical burs and trephines Diagnostic Documentation Bone Splitting System acc. to Dr. Vollmer & Dr. Valentin Orthopantomographical survey record as radiographic basic examination; if required, a digital volume tomography should be taken Articulated models of the maxilla and the mandibula, wax-up Indicator templates for optimal positioning of the distractor on the osteotomized bone segment, observation of the optimized distraction vector Tridimensional visualization in diffi cult cases, e.g. in diffi cult anatomical areas (course of the nervus mandibularis) Requirements on a Distractor A distractor has to be shaped as to guarantee that the gap area and the bone segment which has to be distracted, as well as the periosteum covering, are preferably not pushed aside by metal plates or screws. The distraction vector has to be defined clearly and has to be easily modifiable in case of need. The removal of the distractor should preferably be performed without a second invasive intervention. The Distractor combines these characteristics, allowing a nearly complete relocation of the periosteum as well as a stressless wound closure. The prosthetical construction part allows to change the distraction direction, if necessary. The Distractor saves a time-consuming second intervention with all the negative side effects like stress for the patient, possible wound healing disorder, change of the healing time after insertion of an implant

5 Surgical Intervention Besides local anesthetics or rather block anesthesia, the surgical intervention should preferably be performed under analog sedation or general anesthetic in co-operation with an anesthetist. The fitting accuracy of the prosthetic auxiliary construction (template) either only adjusted to the residual dentition or using the additional auxiliary implant has to be tested in the patient prior to the intervention in order to ensure a safe holding of the distractor sleeve s position during the post-operative impression-taking. Upon local anesthetics, a cut in the vestibulum is recommended. The also allows a cut along the alveolar ridge if the supraperiosteal dissection of the periosteum is performed in the area of the bone segment to be distracted. Afterwards, the periosteum is separated on the alveolar ridge and the bone is dissected lingually and vestibularly, just as far as to allow an access to the envisaged horizontal osteotomy area. Now the horizontal osteotomy line is marked using a fine rose-head bur. The cranial osteotomies are subsequently performed with an oscillating saw or a piezo device. Care must be taken to ensure that the vertical osteotomies are applied in diagonal lateral direction, conically upwards, in order to allow the segment to be moved freely upwards. The bone piece to be distracted shall not be loosened completely in order to allow the distractor sleeve to be placed exactly in the predetermined area, using the drill templates. The distractor sleeve having been positioned, the surgeon releases the bone piece completely using a chisel until the bone can be moved freely (We particularly recommend the chisels from the Bone Splitting System). The vestibular periosteum is fixed lingually with a resorbable suture (recommendation 5.0) by vertical mattress suture. The mucosa is reclined and fixed vestibularly by simple interrupted suture or by continuous suture. The distractor sleeve is then carefully dissected and a gingiva former is screwed into the sleeve. Considering the distraction vector, the Distractor is adjusted with the modified drill template and its position is copied to the template (see prosthesis laboratory part). Herewith, the surgical part the osteotomy is finished for subsequent distraction. In order to minimize complications it is important to perform the surgery speedily and gently. Due to the nourishment of the bone segment, the area of the bone to be distracted shall not be left without sufficient periosteum covering for too long. As infection prophylaxis, the surgical field shall be closed rapidly.

6 1. Initial situation in the front region of the maxilla 2. Radiograph of the initial situation Illustration of surgical opening 3. After preparation of the impression, prior to the surgical intervention, the laboratory prepares the plaster model, the bridge (under consideration of the distraction vector with conventional procedures, respectively CAD-CAM), the drill template and the transfer splint, according to the impression and the planning meeting (in the ideal case, the dental laboratory and the prosthetist are participating in this meeting). to 3. Transfer splint 4. Try-on of the drill template

7 5. Cut along the alveolar ridge 6. Surgical opening / Illustration of the osseous alveolar ridge 7. Determination of the osteotomy areas with a fine rose-head bur ( C) 8. The drill template is fitted 9. Center-punching of the bone block to be distracted, using the drill template 10. Pilot drillings for the distractor

8 11. Vertical osteotomy with diamond disc (Bone block is defined ) 12. Horizontal osteotomy with diamond disc 13. Final drilling for the distractor 14. Turning-in of the distraction anchor ( or ), using the applicator ( or ) 15. Mobilization of the bone block 16. Screwing the modeling unit down ( or ), using the OP distraction key ( or )

9 17. Suturing the surgical wound / relocation of the mucosa and the periosteum 18. Closing the modeling unit with cotton in order to avoid an infiltration of plastic material during the application of the transmission template (Otherwise the modeling units could not be loosened) 19. Insertion of the transmission template. Plastic material is deposited and hardened. The transmission template is subsequently removed 20. Removal after fixation of the modeling unit. Subsequently, framework try-in of the prepared temporary prosthesis 21. The healing caps ( , or ) are screwed onto the distraction anchor, using the OP distraction key ( or ) 22. The patient with distraction apparatus leaves the dental practice until the final bridge is inserted. The healing process takes approx. 3 days

10 23. Finishing in the laboratory. The analogous model ( ) is inserted in the plaster model; bridge with veneer; the distraction screws ( ,.35 or.40) are inserted with the OP distraction key 25. Subsequent distraction of 1 mm ea. per day for a period of approx. 14 days. Important: Daily distraction with the patient s distraction key ( ) in order to avoid fixing of the bone block 24. Insertion of the bridge / of the distractor and slight elevation of the bone blocks. The subsequent healing time takes approx. 1 week 26. As soon as the desired distraction level is reached, the distraction screw is still left in the distraction apparatus for approx. 14 days. Afterwards, the distraction screw is removed by the dentist and the healing cap is attached ( , or ) 27. Healing of the bone segment together with the distraction anchor (approx. 6-8 weeks). Creation of soft bone (callus) under hard bone 28. Removal of the distraction anchor by the dentist, using the applicator ( or ) 29. Insertion of the implant 30. Final treatment

11 Content of the Article No. Description Quantity Price Universal Toolbox, incl. lid for gentle.distract 1 380, Distraction anchor L, sterile 1 68, Distraction anchor XL, sterile 1 68, Distraction screw, short, 12 mm, sterile 1 54, Distraction screw, medium, 14 mm, sterile 1 54, Distraction screw, long, 16 mm, sterile 1 54, Healing cap, short, gingiva height 4 mm, sterile 1 58, Healing cap, medium, gingiva height 6 mm, sterile 1 58, Healing cap, long, gingiva height 8 mm, sterile 1 58, Applicator for distraction anchor (long) 1 70, Applicator for distraction anchor (short) 1 70, OP Distraction key, fi tting distraction screw, healing caps, fi xation screw for modeling units (long) OP Distraction key, fi tting distraction screw, healing caps, fi xation screw for modeling units (short) 1 18,- 1 18, Distraction key for patients 1 18, Analogous model fi g , Modeling unit fi g. 1 (cylindrical) 1 43, Modeling unit fi g. 2 (conical) 1 41, Drill bushing for big anchor drilling 1 25, Wrench with torque and ratchet function, 10 Ncm - 40 Ncm, torque function can be deactivated by fixation function 1 160, C Diamond, round, 029C, Ø 2,9 mm, total length 44,5 mm 1 6, Trephine, inside Ø 4,0 mm, shank 2,35 x 30 mm, 11 teeth, graduation 7/10/13/16 Trephine, inside Ø 4,3 mm, shank 2,35 x 30 mm, 11 teeth, graduation 7/10/13/ , ,25

12 09/12 E We would like to thank our partners: Zahntechnik Martin Zepf Waldbergstraße Seitingen-Oberfl acht Germany Tel.: + 49 (0) 7464 / Fax: + 49 (0) 7464 / Praxisklinik Dr. Frank Kehrer - Dr. Ulrich Jeggle Aspacherstraße Backnang, Germany Tel.: + 49 (0) 7191 / Fax: + 49 (0) 7191 / Responsible for the clinical content: Dental Clinic Dr. Frank Kehrer - Dr. Ulrich Jeggle Seitingen-Oberfl acht, Germany Tel.: +49 (0) / Fax: +49 (0) / info@zepf-dental.com