Dental Implants

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 Contents
• Introduction

• Osseointegration

• Classification of dental implants

• Implant components

• Treatment planning

• Surgical procedure

• Prosthetic phase
• Complications
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• Conclusion
Introduction
• Dental implant is an artificial titanium fixture which
is placed surgically into the jaw bone to substitute
for a missing tooth and its root(s).

• Dental implantology aims at functional and esthetic

rehabilitation of a patient affected by complete or
partial edentulism.

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RATIONALE FOR IMPLANT THERAPY
• Tooth loss related to age
• Anatomic consequences
• Poor performance of RPD
• Predictable long term results of implant-supported prosthesis
• Eliminating the need to grind healthy tooth
HISTORY OF DENTAL IMPLANT
• 1950s [Link] & associates
• 1965 first patient
• 1976 Schroder et al.
• 1978 Schulte(German)
• 1981 Albrektsson
osseointegration

• A Swedish orthopedic surgeon, Prof Branemark, in

1952 accidentally discovered osseointegration.

• When pure Ti comes in contact with the living bone

tissue the two literally grow together to form a
permanent biological adhesion.

• Functional ankylosis- also called

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OSSEOINTEGRATION
• “A direct structural&functional connection between bone and the
surface of a load-carrying implant”(Branemark 1960)
• Fibro-osseous integration
-soft tissue(fibres)interposed between the implant surface & bone
• Biointegration
-implant is covered with bioactive material like hydroxyapatite
Factors for successful osseointegration.

• Biocompatible material- Ti, either commercially pure

or in certain alloys.
• Prrimary implant stability- it should be precisely
adapted to the prepared bony site
• Atraumatic surgery to minimize tissue damage
• An immobile, undisturbed healing phase.

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Titanium
• Biocompatibility is due to its surface oxide

• When exposed to air it forms a dense 4-nm layer of

Titanium dioxide TiO2 - chemically stable and very
corrosion-resistant.

• 4 grades of commercially pure titanium-differing with

percentage of trace impurities in the [Link]
greater the contaminants the harder the metal.
• Grade 4 cpTi - commonly used for dental implants.
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• Grade 5 -Titanium alloy- [Link] equal
biocompatibility but better tensile strength and
fracture resistance than cpTi.

• Zirconia- similar in biocompatibility, improved

cosmetics, fracture resistance lower,can be used as
only one piece.

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Steps of osseointegration

• Woven bone is quickly formed in the gap between

the implant and the [Link] has low biomechanical
capacity,- the occlusal load should be controlled

• After 1 to 2 months, under the effect of load, the

woven bone will slowly transform into lamellar bone

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IMPLANT TISSUE
INTERFACE
• Implant and bone interface- The glycoprotein layer on
the bone is adsorbed on the implant surface with the
help of adhesive macromolecules like Fibronectin,
Laminin.

• They are bonded to the metallic oxide layer on the Ti by

covalent bonds, ionic bonds or van-der-walls bonding.

• Implant connective tissue interface- gingival fibers

forms the attachement , is strong enough to withstand
the occlusal forces and microbial invasions.
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• Implant epithelial interface-Epithelium is attached to
implant surface through hemidesomosomes and
glycoproteins and considered as Biologic seal.
• It forms a sulcus depth of 3 to 4 mm.

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Classification of dental
implants
• Based on implant design (TYPE OF ANCHORAGE)

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Endosteal implants - A device which is placed into the
alveolar bone Transect only one cortical plate
• Blade/plate implant-thin plates in the form of blade
embedded into the bone

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• Ramus frame implant-Horse shoe shaped stainless
steel device. Inserted into the mandible from one
retromolar pad to the other and passes through the
anterior symphysis area

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• Root form implant - Designed to mimic the shape of
the tooth and for directional load distribution

• Forms:
• Cylinder
• Screw root form
• Combination

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SUBPERIOSTEAL (EPIOSTEAL) IMPLANT

• Placed directly beneath the periosteum overlying the

bony cortex,indicated in cases with inadequate bone
height for endosteal implants.

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• TRANSOSTEAL IMPLANT (Mandibular staple implant)

• Penetrates both cortical plates

• It has subperiosteal and endosteal components.

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INTRAMUCOSAL IMPLANTS

• Inserted into the oral mucosa. Mucosa is used as

attachment site for the metal inserts of removable
dentures

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Based on shape and form:

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• Based on the surface
texture
-surface with
pure titanium
-acid-etched
surface
-porous
beaded surface
-
hydroxyapatite
coated

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• Based on surgical timing

1. Immediate post-extraction implant.

2. Delayed immediate post-extraction implant. (2 weeks
to 3 months after extraction).
3. Late implantation (3 months or more after tooth
extraction).
• According to the timing of loading of dental implants

1. Immediate loading procedure.

2. Early loading (1 week to 12 weeks).
3. Delayed loading (over 3 months)

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IMPLANT COMPONENTS

1. Implant body
2. Healing screw
3. Healing abutment
4. Impression coping
5. Analogue or Implant Replica
6. Abutment
7. Prosthetic crown

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Implant body

• The component that is

placed within the bone
during first stage of surgery

• It could be threaded or non

threaded, with or without
a hydroxyapatite coating
Healing screw (First stage cover
screw)

• It is placed into the top of the

implant to prevent bone ,soft
tissue or debris from invading
the abutment connection area
during healing.
• It facilitates suturing of the soft
tissue

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Healing abutment

• It is a temporary part placed on the

implant body to create a channel
through the mucosa while the
adjacent soft tissues heal and results
in a perimucosal seal around the
implant.

• Also called as permucosal extension

or gingival former.

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Impression coping (impression cap)

• It is used to transfer the position of the implant body or

the abutment to the working cast.
• The dentist screws the impression coping to the real
implant body and then takes an impression.
• The impression coping remain fixed in the impression
material and lab analogue is added prior to dispatching
to the lab.

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Analogue or Implant
Replica

• Analogues are used by lab

technicians to replicate
implants and their
position in a patient’s
mouth.
• A model of the patient’s
dentition is made using
an impression.

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Analogue provides a replica of the position of the implant from
which the technician can place and shape the abutment and
build the crown.
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Implant abutment

• Intermediate connector between

the implant and the restoration, it
may extend above the tissue.
• Supports or retains a prosthesis.

• 4 types: cylindrical, shouldered,

angled and customizable
• Shouldered designs provide
natural-appearing emergence
profile

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 TREATMENT PLANNING
Clinical evaluation

• Medical history
• Current dentoalveolar condition
• Local evaluation of site for implant placement -Alveolar bone
height, width, and jaw relationship and prosthetic restorability.
• Intraoral bone mapping - probe through the soft tissue to
assess the thickness of the soft tissues and measure the bone
dimensions at the proposed surgical site.
• Patient's expectations – Reasonable or not
• Oral hygiene status

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Radiographic evaluation

• 2D- periapical, occlusal, panoramic, lateral

cephalometric radiographs.
• 3D- CT,Tuned aperture computed tomography, cone-
beam CT, MRI

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Study model analysis

• To determine

• Clinical length of the prosthetic crown that will be

supported by the implant. (Crown-implant ratio).
• Inter arch distance.
• The implant axis- it should be parallel to the axis of
adjacent natural teeth.
• Number and size of implants.
Surgical guides

• Helps to position the implants appropriately from the

prosthetic point of view.
• Holes are drilled into the acrylic at appropriate locations
with proper axis orientation.
Stereolithography

• From the available CT data a model can be created from a

solid block of material by means of a computer guided
milling device.
• Advantages:
• Precise evaluation of the actual osseous condition.
• Surgical therapy can be precisely planned preoperatively for
determination of the most favorable implant axis orientation.
• Helpful for evaluating the relationship of mandible to maxilla.
FACTORS AFFECTING
TREATMENT
Implant position,Number,Size and design depends on

• Implant Prosthesis design- Implant supported denture,

over denture or FPD.
• Patient force factors- Para functional habits,
masticatory forces, Crown height,Occlusion.
• Bone density

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 BONE EVALUATION

• Bone height - Minimum for long term survival is 10 mm

It is 12 mm in the posterior mandible because of nerve
proximity.

• Bone width - The minimal width should be 6 to 7 mm.

• Bone length -
• length refers to mesio distal distance
• 1.5 mm from adjacent tooth & 3 mm from adjacent implant,
Should be 2 mm from adjacent anatomical barrier.
• So a 5 mm implant requires atleast 8 mm length of the bone
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• Bone angulation

• Ideally it is aligned with the forces of occlusion & is parallel

to the long axis of prosthodontic restoration.
• Premolar region-10°
• 1 st Molar -15°
• 2 nd Molar-20-25°
• For Wider ridge 30° is acceptable

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• Implant size

• Mand. Incisors and Max. LI=3-

3.5mm
• Max. anterior,PM of both arch
and [Link] =4 mm.
• For all Molars =5-6mm
• The minimum amount of
interocclusal space required for
the restorative “stack” of
implant is 7 mm.

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• Crown : Implant

• Most ideal – 1 : 2
• More common – 1 : 1.5
• Minimum requirement – 1 : 1

• As the Crown : Implant increases the number of implants

& / or wider implants should be inserted to counteract
the increase in stress.

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Bone density

• For softer bone, number and diameter of implant

must be increased with more and deeper threads.
• Bone density can be assesed by Misch classification on
bone density (1988) from C.T using Hounsfield Units
or C.T number.
• He classified it in to 4 groups D1 to D4. and D5 is
immature bone.
• Higher the CT number, denser is the tissue.
• D1: > 1250 HU; D2: 850 to 1250 HU; D3: 350 to 850
HU; D4: 150 to 350 HU; and D5: < 150 HU.

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Misch classification on bone density(1988)

D5 Immature, nonmineralized bone

Surgical procedure
• Surgery can be done in one stage or in two stage.
• 2 stage surgery-In first stage implants are surgically
placed under the gum and the patient is made to wait
for 6 months for osseointegration
• 2nd stage surgery is then performed where the healing
gingival former is placed and after a week of satisfactory
formation of a gingival collar for emergence profile is
achieved, impressions are made for implant prosthesis,
which may be cemented or screw retained
• one-stage surgery –Implant is placed and left exposed
through the gum. In this case, a second stage surgery in
not needed
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Preoperative care

• Surgical site preparation and isolation

• Preoperative antibiotic prophylaxis - oral dose of 2
g penicillin V 1 hour before
• Local anesthesia

• Incision- Mid crestal incision with a margin of

1.5mm keratinized tissue buccally extending to the
sulcus of adjacent teeth
• Flap should be reflected and elevated.
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Implant osteotomy

• After the bone is exposed the surgical guide template

is [Link] directs the angulation of the implant.

• A low-speed (1500-2000[rpm]),high-torque
handpiece and copious irrigation are necessary to
prevent excess thermal injury to the bone

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Irrigation :
• keeps the local bone temperature
at normal body temperature and
also to flush out the bone debris
from drill hole.
• NS at room temperature is ideal.
• Various types of physiodispensers are available which
can controll speed,torque,and irrigation.
Bone Drilling

• The manufacturers give a guide to the

sequence of drill(Sizes) to be used in order to
make proper sized drill hole for a particular
implant
• The drills are marked for depth to guide
the surgeon.

• Drills are used in ascending order of diameter.

• Recommended drilling speed- < 800
rpm
• With the initial drill, the center of the implant
recipient site is marked and the initial pilot hole is
prepared
• A paralleling pin is placed in the initial preparation to
check alignment and angulation .

• If it is appropriate,drill hole is sequentially enlarged to

dimensions of the implant.

• After the desired depth and diameter of the recipient

site is accomplished, the implant can be placed.

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Implant placement

• After final osteotomy, the site is lavaged and aspirated to

remove debris and blood.
• For Ti implants, an uncontaminated surface oxide
layer is necessary to obtain [Link]
touching with gloves, soft tissue or a dissimilar metal
should be avoided.

• The implant is rotated with 30 rpm by low speed high torque

hand piece /hand ratchet.
• It should be rigid with no mobility on slight compression
• Post insertion radiograph- to evaluate the position , adjacent
vital structure.

• Cover screw is inserted. Flaps are sutured.

• If implant position is not correct,it may be removed and
reinserted after several months later.
• Second stage surgery

• In second stage surgery in prefferably a ‘+’ shaped

incision is made in the overlying mucosa and the cover
screw is exposed and removed with a Hex Driver, and is
replaced with a gingival former and is left for 7 to 17 days

• The gingival former helps in formation of a gingival collar

around the future abutment which helps in giving the
final prosthesis a more natural appearance.

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 Prosthetic phase
Impression :

• After the healing period,gingival former is removed,impression

copings are put onto the implant and impression is taken by
open/closed technique.
• The implant analogue is fixed on the impression coping and the
impression is poured in die stone.
• Now the analogue is seated in die with same
angulation as in bone.
• Once the plaster is set the the coping is removed and
abutments are placed over the lab analogue.
• Then the crown is fabricated over the abutment.
• After the fabrication of prosthesis, the abutment is
taken off the cast leaving the implant analogue in
the cast.
• This abutment can now be transferred and screwed
onto the implant and prosthesis affixed to it (either
screwed or cemented to the abutment)
• Occlusal adjustments are undertaken if required

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Complications
• Intraoperative
• Flap tear
• Insufficient irrigation
• Perforation of buccal or lingual cortex
• Inferior alveolar nerve injury
• Implant/Drill impinges on adjacent tooth root
• Perforation of maxillary sinus
• Perforation of pyriform fossa base
• Lack of primary stability of implants
• Fracture of implant
• Immediate postoperative
• Swelling
• Nerve injuries
• Pain(unusual)
• Haemorrhage(Rare)
• Delayed
• Infection
• Secondary Haemorhhage
• Nerve injury
• Loosening of implant
• Implant Exposure

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Implant failure

• Mobility of implant during healing period

• Pain , infection
• Radiolucency around implant.
• whatever the cause,the implant should be removed.
• Grafting and reinsertion can be done after 8-10wks.
Complementary procedures

• Bone grafting for implants- Done when the bone is

too narrow or too short to place an adequate sized
implant.

Sinus lift

• Our sinuses are located in close proximity to the

upper posterior jaw bone. In some cases, the sinus
floor "dips" down, causing that area to lose bone
height,then a "sinus lift" procedure is necessary in
order to increase bone height.
• A cortical window 2 to 3 mm above the sinus floor is created with
round bur down to the membrane of the sinus.
• Careful in-fracture of the window with dissection of the sinus
membrane off the sinus floor creates the space necessary for graft
placement; the
• Corticocancellous blocks may be placed in the resulting defect.

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Conclusion
• Dental implants have overall had high success rates, but their
placement and restoration still have the boundaries of both
biomedical science and art.

• The effectiveness of different designs of implant-supported

prostheses as well as associated treatment modalities leads to
improvement in speech, function and quality of life.