Classification of the Surgical Procedures

Preventive Procedures
 Routine measures after extraction.
 Alveoloplasty and alveolectomy.
Corrective Procedures
 Soft Tissue Surgery
 Labial frenectomy.
 Lingual frenectomy.
 Removal of denture granulomata.
 Correction of flabby ridge.
 Hard Tissue Surgery
 Removal of tori.
 Correction of prominent mylohyoid ridge (Lingual
balcony).
 Correction of knife edge ridge.
Ridge Atrophy Procedures
 Vestibuloplasty.
 Ridge Augmentation.
 Implants.

Dental Implants

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 Osseointegration :
direct structural and functional connection between
the living bone and the surface of implant without
interposition of connective tissue

Factors that Determine Osseointegration

1. Biocompatibility of the implant material

2. Implant geometry

3. Systemic factors

4. Surgical technique

5. Occlusal load

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 Implant design

Threaded Implant

Threaded implants have demonstrated maintenance of a

clear steady state bone response.
To enhance initial stability and increase surface contact,
most implant forms have been developed as a serrated
thread.

Bone Quality
• Density I

Was composed of homogenous compact

bone, usually found in the anterior
lower jaw.

• DensityII

Had a thick layer of cortical bone

surrounding dense trabecular bone,
usually found in the posterior lower
jaw.

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 • Density III
Had a thin layer of cortical bone
surrounding dense trabecular bone,
normally found in the anterior upper jaw
but can also be seen in the posterior
lower jaw and the posterior upper jaw.

• Density IV
Had a very thin layer of cortical bone
surrounding a core of low-density
trabecular bone, It is very soft bone and
normally found in the posterior upper jaw.
It can also be seen in the anterior upper
jaw.

Preoperative Examination of Potential Implant Patients

Clinical Examination
This includes
- Patient’s current health status and
medications
- Details of past medical history and medical treatments.
- Patients should be questioned about parafunctional habits,
oral hygiene, and personal habits such as tobacco, alcohol,
and drugs.
- The understanding, and expectations of the patient are
important for optimal treatment outcome.

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 Patient with radiotherapy or chemotherapy?

- Extra-oral examination
(lip line, lip competence, and temporomandibular joint).

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 - Intraoral assessment
Should include assessment of the
edentulous space, occlusion, status of
adjacent and opposing teeth, overall
periodontal status, presence of other
implants and restorations, shape of the
teeth, gingival biotype, and any other local
factor that may impact the success of the
treatment.

Diagnostic study models and intraoral

clinical photographs are essential for
documentation as well as for the further
assessment of spatial and occlusal
relationships.

Radiographic Examination

The radiograph of choice is the Cone Beam Computerized

Tomography (CBCT) as it provides a detailed three-
dimensional analysis of the edentulous area along with the
neighboring anatomical structures.

With the software for CBCT, it is possible to measure

accurately the dimension of the site and distances from
critical structures and accurately plan which implant
dimension would be appropriate.

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 Small voxel size Increase No.

High image quality

X-Ray C Arm rotates 360 degrees around

imaging area and x-rays are accurately detected

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 CBCT Reference Planes

Axial Sagittal

Coronal Transaxial

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 Axial Plane
This is an
Axial image..
(Transverse)

…that
represents
this area of
anatomy

Axial view
- Its divided the body into
superior and inferior.
- Used for evaluate the crown,
root, bone, and c shape canal.
- It can be used to evaluate
medial & distal area

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 Coronal Plane

Click

Coronal view
- Its divided the body into
anterior and posterior
- In anterior area used for
evaluate the mesial & distal
surface of tooth
- In Posterior area used for
evaluate Lingual and buccal
surface.

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 Sagittal Plane

Click

Sagittal view
- Its divided the body into Right
and left.( Medial & lateral)
- In anterior area used for
evaluate the Lingual and
buccal surface.
- In Posterior area used for
evaluate mesial & distal
surface of tooth

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 Series of Cross-
Sectionals/Transaxials
Cross sectional images of an area can be
developed with 0.5 to 5mm spacing between
images.

Clinical Applications of CBCT -Dental Implants

Preparation

Immediate Smile Implant planning

Surgery with SurgiGuides

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 Clinical Applications of CBCT -Dental Implants

CBCT
Nerve Mapping

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 Limitations of CBCT

- Artifact
- Image noise
- Poor soft tissue contrast
- Low resolution
- Bone Density depend on gray scale value

CBCT scan– showing axial view (A) with curved line (red solid line)
for “panoramic” view (B) and set of cross-sections, 1-mm-thick images
(C) of a potential implant site in the lower left mandible. Blue lines on
the axial and panoramic images indicate the location of the cross-
sections. Apart from information of bone quality and dimensions, the
cross-sections reveal the amount of lingual undercut and location of the
inferior alveolar canal (green).

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 Three Dimensional visualization of right parasymphysis fracture of
mandible on CBCT scan – Panoramic view (A), Axial view (B) and 3D
(C, D, E).

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 Correct 3-Dimensional Position for an Implant

For the site of implant placement, the available space

should be evaluated in three dimensions, i.e., mesiodistal,
buccolingual, and apicocoronal dimensions.

Evaluating the available space, factors such as proximity to

adjacent anatomical structures such as maxillary sinus,
mandibular nerve, nasal floor, adjacent tooth roots, etc.
should be considered.

The minimal space required for an implant depends on the

size of the implant to be used (in terms of length and
diameter), whether the implant is placed adjacent to two
natural teeth or adjacent to an implant and the apicocoronal
distance in the bone.

1. Implant adjacent to a natural tooth

2. Implants adjacent to each other

Comfort zones (which is the ideal position for an implant)

Danger zones (in which implants should not be placed).

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 Implant adjacent to a natural tooth:
This was defined in three directions mesiodistally,
coronoapically, and orofacially.

The ideal mesiodistal distance between a natural tooth and

the shoulder of an implant is 1.5 mm. ( to avoid bone loss)

The zone 0–1.5 mm from the adjacent teeth on either side

was the danger zone. Between the danger zone was the
comfort zone that is safe for implant placement.

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 In the apicocoronal direction, the apex of the implant
should be at least 1-2 mm away from any anatomical
structure such as nerve, sinus, or tooth roots.

Also, in the shoulder of the future implant should be at least

1 mm apical to the cementoenamel junction of the adjacent
teeth to allow for a proper emergence profile.

Placing an implant too deep will result in too much

countersinking, difficult handling, and facial mucosal
recession. Placing an implant too superficially will cause the
metal margin to be visible and improper emergence profile.

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 (a) (b)

(a) A severe recession of the mucosa has occurred owing to a

facial malposition of the implant in the upper left central incisor
site (site 9). (b) Cone beam computed tomographic scan of the
implant showing the facial malposition of the implant

In the orofacial dimension, the implant shoulder is

positioned palatal to the incisal edge of the future
restoration (or 1 mm palatal to the point of emergence of
the adjacent teeth).

The oral aspect has a danger zone as well, indicating that an

implant should not be placed too far orally to prevent the
use of a angulated abutment.

Too far facially will result in increased mucosal recession.

In addition, the ideal facial bone thickness should be 2 mm

and the lingual bone thickness should be 1.5 mm

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 The height (H) of the
interdental contact from
the crest of the interdental
alveolar bone should not
be more than 5 mm for
obtaining adequate
interdental papillary
morphology.
The interimplant distance
(D) should be at least 3 mm
for obtaining adequate - Avoid in midline of maxilla.
interdental papillary
- 2mm from superior aspect of
morphology.
IAN canal.
- 5mm anterior of mental nerve
bony foramen

Timing of Implant Placement Postextraction

- The ridge width reduction of up to 50% occurred

during the first year after tooth loss in premolar and
molar sites, and two-thirds of the total change took
place within the first 3 months following extraction.
Dimensional alterations occurred in both height and
width, with approximately 2.6–4.5 mm in width and
0.4–3.9 mm in height.

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 Concept of Timing for Implant Placement
Type 1: When placed immediately after tooth extraction, it
is called immediate implant placement.
Type 2: When placed 4–8 weeks after tooth extraction, it is
an early implant placement with only soft tissue healing
Type 3: When placed 12–16 weeks after tooth extraction, it
is an early implant healing with partial bone healing
Type 4: When placed after 6 months after tooth extraction,
there is complete bone healing, and this is called delayed
implant placement.

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 Surgical Procedure for Conventional Implant Placement

For standard implant placement:

1. Local anesthesia: the area of surgery including at least two

teeth mesial and distal should be well-anesthetized.
2. Incision: a scalpel blade no 15 is used to make a horizontal
paracrestal incision. If required, a vertical release incision can
be given on the distal aspect to create a triangular flap.

3. Flap elevation: A full thickness mucoperiosteal flap is

elevated on the buccal and on the lingual aspect. The crestal
bone should be exposed sufficiently so as to get visible access
to the implant site as well to check the palatal and buccal
curvature of the ridge.

4. Flattening of the ridge: A large round rose bur is used to

flatten the ridge, thus removing any bony slopes in the crestal
area. This also allows removal of the narrower portions from
the crest of the ridge; however, extensive removal in short
ridges should be done carefully.

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 5. Drilling of the osteotomy: all drilling should be done along
with copious amounts of cold saline irrigation with the speed
as specified by the manufacture for each particular bur/drill
(generally in the range of 800–1500 rpm). It is important to
keep an eye for the correct positioning and the neighboring
anatomic structures during each stage of drilling.

(a) Initially, a small diamond bur is used to mark the site. The
mark created corresponds to the center of the osteotomy and
should be in the correct position. This bur is used to make a
hole of 1–2 mm deep to create a start point for the pilot drill.

(b) The pilot drill is the first twist drill used to create the
osteotomy up to the desired length. Ideally, the length of the
osteotomy should be slightly more than the implant so that
the implant can be placed slightly subcrestal (to compensate
for future crestal bone resorption). Also, the shoulder of the
future implant should be 1 mm apical to the cementoenamel
junction of the adjacent teeth in esthetic areas to allow for a
proper emergence profile.

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 If multiple implants are to be placed, a guide pin is used in the
first osteotomy to align the second implant before
commencing the second osteotomy preparation.

(c) Subsequent drills are used in the same way as the pilot
drill to enlarge the osteotomy to the desired depth.

(d) The countersink drill also flares the preparation to allow

the placement of the cover screw over the implant without
any bony interference.

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 6. Implant placement: implants are placed with a handpiece
at slow speeds (18–25 rpm) or by hand using a torque
wrench. Implant insertion should follow the same path of
insertion as that of the osteotomy. For multiple implants,
guide pins serve as a direction indicator to obtain parallelism.

Care is taken to insert the implant such that the microrough

surface of the implant is 1–1.5 mm subcrestal. This prevents
exposure of the rough surface of the implant to the
environment during the eventual crestal bone remodeling.

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 Once the desired position and stability are achieved, the
cover screw (for submerged healing)/healing abutment
(nonsubmerged healing) should be fitted over.

7. Flap closure and suturing: the flap should be approximated

so as to provide tension-free closure. If required, a periosteal
release incision can be done. If a submerged healing is
planned, the flap should be completely closed over the
implant by primary closure. If a nonsubmerged healing is
intended, then the flap is closed around the healing
abutment. Although any technique of suturing is acceptable,
it is preferable that for long horizontal spaces, horizontal
mattress sutures along with interrupted sutures are placed in
4–0 or 5–0 nonresorbable sutures.

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 8. Postoperative care:

- Simple implant surgery in a healthy patient does not require

antibiotic coverage; however, if the patient has any systemic
complications or at risk of infection, it is advisable.

- Analgesics are recommended for the first few days after

surgery.

- Patient is given routine postsurgical instructions such as use

of ice packs for the first 24 h, soft diet, no vigorous rinsing, no
brushing on the surgical site, no tobacco smoking, and no
vigorous exercise.

9. Prosthetic phase: depending on the choice of timing to

load the implant, the reopening phase can be planned.

- For nonsubmerged implants, often, no second surgery is

required as the healing abutment is exposed.

- For submerged implants, the healing cap/abutment can be

exposed by a small surgical procedure and healing abutment
can be inserted so as to allow the mucosal tissue to heal
around and create an emergence profile.

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29
 Implant failure and management

The criteria that define the success of dental

implants include:

- The absence of mobility at the start of the

prosthetic phase

- The absence of continuing radiolucency around the

implant

- The absence of peri-implantitis with suppuration,

and subjective complaints from the patient.

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 Implant success rates include:
- Implant location in the upper or lower jaw and its position
in the dental arch.

- Implant type, diameter and length.

- Prosthetic construction.

- Used for single tooth replacement or in an edentulous

month.

Classification of implant failure

- Ailing implant: Implants exhibiting soft tissue problems.

- Failing implant: An implant that is progressively losing its

bone anchorage, but is still clinically stable, can be defined
as failing.

- Failed implant: Implant with mobility excessive bone loss

(>70%) not amenable to treatment are failed implant.

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 A. According to etiology C. According to timing of failure

- Host factor - Before stage II

- Surgical factor - After stage II

- Implant selection factor - After restoration

- Restorative factor D. According to failure mode

B. According to condition - Lack of osseointegration

- Ailing Implant - Unacceptable aesthetics

- Failing Implant - Functional problems

- Failed Implant - Psychological problems

E. According to supporting tissue

- Soft tissue loss

- Bone loss

- Combination

F. According to origin

- Peri implantitis

- Retrograde Peri implantitis

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 Parameters used for evaluating failing/failed implants
1. Clinical Signs of Early/Late Infection
2. Bleeding on probing
3. Probing Depths
4 Pain or Sensitivity
5. Clinical Discernible Mobility
Exposure of left implant and soft
6. Radiographic Signs of Failure
tissue inflammation overlying the right
7. Dull Sound at Percussion implant.
The mean bone loss
around implants is 1.5- 1.6
mm for the first year,
followed by a mean bone
loss 0.1- 0.13 mm per year.

A bone scraping device is Removal the ramus bone graft

used to harvest particulate
bone from the ramus region.

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 Peri-implant bone loss management. (A) Radiolucency in
coronal third of the implant; (B) Flap reflection and
debridement; (C) Grafting with bone graft and membrane
placement; (D) Decreased radiolucency around implant

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