1

Seminar
on
Dental
Implants
Dr Deepa V S
III MDS
 Quick through
Introduction
History
Rationale for implants
Classifications
Biological aspects of implant
Components of implant
Components of implant kit
Biomaterials for implants
Clinical aspects of dental implants
Diagnostic Imaging of the Implant of Patient
General principles of implant surgery
Complication related to implants
Conclusions

2
 Introduction

Tooth loss is the one of commonest oral

finding in the human population.
With increasing health expectancy, there is
demographic shift in population who seeks
the treatment for the tooth loss.
Increased expectations of the individuals
keep the ever increasing challenge on the
dental therapists for better treatment
options.
3
 Also the standard of care is continually
evolving with the advent of new materials,
new procedures and new court rulings.
So therapists are always in search of best
possible treatment for long term benefit of the
patients.
Dental implants are one of the such option
which has better advantages over the
conventional prosthetic treatment modalities
(like CD, RPD & FPD) . 4
 Implants are the material other than an
organ or tissue from another body
(transplant) inserted or grafted into an organ
or structure of the body for therapeutic or
other biologically important function.
Similarly dental implants are the
biologically inert materials which are
placed into the oral cavity for se in the jaw
bones for the replacement of tooth.
5
 History

Origin, began as early as the Greeks,

Etruscans, and Egyptians.
These civilizations employed different
designs and materials ranging from jade and
bone to metals to replace the teeth.
Albucasis de Condue (936-1013) used ox
bone for replacing missing tooth and was
first documented placement of implant.
6
7
 Breakthrough in science of implantology were
research of Branemark et.al in the late 1950s,
and Schroeder et.al in the mid-1970s.
Established that direct contact exists between
bone and titanium implants and that this contact
results in the clinical stability of an implant
during loading.
For this Branemark and co-workers coined the
term "osseointegration" in 1967.
8
 Advantages in implants in single tooth edentulism
FPD
Mean life span reported at 10 yrs 50% survival
Caries most common causes of failure
15% abutments require endodontic treatment
80% abutments have no or minimal restoration,
(even need to prepare, most damaging in
youngsters)
Unfavorable outcomes may leads to loss of FPD
along with abutment
Periodontal health of abutment damaged
Implant
High success rates at 10 years 97%
Decreased risk of caries on adjacent teeth
Decreased risk of endodontic problems on
adjacent teeth
No need for abutment preparation
Individual system will fail
Minimal or no damage to periodontal health
of adjacent teeth
Improved esthetic
Improved maintenance of bone
Decreased cold or contact sensitivity of
adjacent teeth
Improved ability to clean
Psychological advantage to patient
9
 RPD & CD compared
to Implants
Negative effects of Removable prosthesis:
Bite force decreased from 200 to 50 psi
Masticatory efficiency is decreased (20-
30%)
Life span may be decreased
Food selection is limited.
Denture stability -mandibular dentures.
Occlusion is difficult to establish and
stabilize 10
 Advantages of
implant prosthesis
Maintenance of bone
Restore and maintain vertical occlusal dimension
Improves esthetics , phonetics & occlusion
Improve /regain oral proprioception
Increases prosthetic success
Improves masticatory performance

11
 Reduced size of prosthesis (eliminate palate and flanges)
Improves stability and retention of removable prosthesis.
Increased survival time of prosthesis.
No need to alter the adjacent teeth.
More permanent replacement.
Improves psychological well being.

12
 Based on these rationales the implant
supported prosthesis are always the better
treatment options except in conditions
where the anatomic landmarks limits the
implant placement.

13
 Classification

Implants can be classified as per its:

-design,
-properties &
-attachment mechanisms

14
 Classification as per Implant
Design

Endosteal implants
Subperiosteal implants
Transosteal implants
Epithelial implants

15
 Endosteal implants:

First and most commonly used type

Placed into the alveolar and/or basal bone of the
jaws and transacts only one cortical plate
Various shapes are blade form, Ramus frame
implants, root form implants.
Most popular endosteal implant is the root form
implant, which mimics the root of tooth.

16
 Subperiosteal implants

was first developed by Dahl (1940) and refined by

Berman (1951)
It has a substructure and superstructure
custom-cast frame is placed directly beneath the
periosteum overlying the bony cortex
Use has been limited because of numerous
disadvantages, which include slow, but predictable
rejection of the implant, difficult retrievability, and
excessive bone loss associated with failure.
17
 Transosteal implants

It combines the subperiosteal and endosteal

components
penetrates both cortical plates of the jaw
bone
concept of transosseous implants was first
conceived in Germany in the early 1930s.
is restricted to the anterior area of the
mandible and provides support for tissue-
borne overdentures 18
19
 Epithelial Implants

These are inserted into the oral mucosa.

It has a very simple surgical technique and
requires that the mucosa be used as an
attachment site for the metal inserts.
disadvantages associated are most notably
painful healing and the requirement for
continual wear, which probably explains
why it is no longer used.
20
 Classification as per Implant
Properties
Implant biomaterials can also be classified
according to their composition and their
physical, mechanical, chemical, and
biological properties.
This includes ranked comparisons of
properties such as elastic modulus, tensile
strength, and ductility to determine optimal
clinical applications.
These properties are used to aid in the
design and the fabrication of the prosthesis.21
 Classification as per Attachment
mechanisms
Historically, implant attachment through
low-differentiated fibrous tissue was widely
accepted as a measure of successful implant
placement.
It was termed as pseudo periodontium but it
was mainly because of faulty procedure and
lead to most of failures of implants.
Other mode of attachment which is the
widely accepted terminology today is the
osseointegration. 22
 Stages of bone healing &
osseointegration
Osseointegration process observed after
implant insertion can be compared to
process of fracture healing.
Logically certain immobility of the implant
towards the bone surface should be
maintained.

23
 A mild inflammatory response, as triggered by
movements or appropriate electrical stimuli, may
enhance the bone-healing response, but to a
certain threshold level.
If this micromovement exceeds 150um,
differentiation to osteoblasts will not occur,
rather a fibrous scar will be laid down around the
implant
Therefore, such forces should be avoided in
early healing period.

24
 If the neighboring bone has been overheated or
crushed during drilling, the formed necrotic
area will prevent in growth of stem cells, and a
scar formation or sequestered formation will
result.
The critical temperature for bone cells is as low
as 47 C at an exposure time of 1 minute.
This corresponds to the denaturing temperature
of alkaline phosphatase, the main bone cell
enzyme.
25
 The implant placement thus implies profuse
cooling with intermittent moderate speed
drilling with sharp drills.
Another complicating factor is microbial
contamination which jeopardizes the
normal bone repair, thus aseptic techniques
should be maintained.

26
 The preosteoblasts derived from the invading
primary mesenchymal cells, depends on a
favorable redox potential of environment.
Thus proper vascular supply and the oxygen
tension are needed.
If this favorable conditions are not met the
primary stem cell may differentiate into
fibroblasts and implant will be facing scar
tissue.

27
 In healing process first, woven bone is quickly
formed in the gap between the implant and the
bone.
Second, after several months, this is progressively
replaced by lamellar bone under the load
stimulation.
Third, a steady state is reached after about 1.5 years
Often, for oral implants, occlusal load is allowed as
soon as 2 to 3 months while mostly woven bone is
present
28
 Woven bone

It is characterized by random orientation of

collagen fibers, high cellularity, and limited
degree of mineralization.
It grows by apposition, originating from bone
lesion or by conduction, using implant surface
as scaffold.
Implant surface characteristics such as material
properties, surface energy and roughness
profiles are determining factors that influence
29
 Altered surface topographies such as those
created by acid etching, blasting, or
increasing the titanium oxide layer shows
greater bone apposition as compared to
turned or machined surface.

30
 Lamellar bone

After 1 to 2 months, under the effect of

load, the woven bone surrounding the
implant will slowly transform into lamellar
bone.
It is more regularly organized & highly
mineralized than woven bone.
Contrary to the fast growing woven bone,
lamellar bone apposition occurs at a slow
pace with few microns per day.
31
 Effect of implant surface free
energy
It is the property of implant to adsorb the
surrounding biomolecules on its surface
when is placed into tissue :- wettability.
The surface topography of the implant
determines this property- microscopic
roughness.

32
 Roughened implant surfaces speed up the
adsorption and ultimately the bone
apposition.
But disadvantage
favors local plaque & calculus
accumulation,
increased ion leakage which is detrimental
for long term bone health (TPS and HA
coated). 33
 Rigidity and strength of established
bone to implant surface
It depends upon factors such as bone quality,
surgical factors, implant characteristics, and
physical properties of both implant and bone.
Basically the implant stability in the bone is
grouped into two stages.
Primary - at the time of implant placement.
Secondary - after the initial healing phase.

34
 Primary stability

It depends on the factors such as bone

mineral density, available volume, the
relation between drill and implant diameter.
Denser the bone, higher the volume the better
the initial implant stability.
Also the mineralization of bone affects the
initial implant stability. An established
relationship exists between a bone mineral
density and implant rigidity.
35
 Secondary stability

It mostly depends upon the care of implant

exercised during surgical procedure and
during the postoperative healing period.
More the gentle surgical procedure better
will be healing and better stability.
Similarly better the implant is protected
from the functional occlusal stresses in
healing period better the stability.

36
 Overload, may cause microstrains and
microfractures, which will lead to a bone loss at
the interface.
Lack of load can also be detrimental and can lead
to cortical bone resorption.
Both these factors determines the long term
success and survival of implant.
Assessment of implant biomechanics can easily
be done at the clinical level by noninvasive
devices such as the Periotest and the Ostell.

37
 Soft tissue interface
Soft tissue relationship around implants is
comparable with teeth.
It can be a keratinized mucosa, or a non-
keratinized mucosa,
The interface between epithelial cells and the
titanium surface is characterized by the
presence of hemi-desmosomes and a basal
lamina.
Histologically, it cannot be distinguished from
those structures around teeth.
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41
42
43
 Reaction patterns toward plaque at both the light
microscopic and the ultrastructural level are
similar to those of tissues surrounding teeth

From many prospective and cross-sectional

studies related to screw-shaped implants with a
machined surface, it appears that presence or
absence of keratinized gingiva, just as for teeth, is
not a prerequisite for long-term stability.

44
 COMPARISON OF TISSUES SURROUNDING
NATURAL DENTITION AND OSSEOINTEGRATED
ORAL IMPLANTS:

Although the soft tissue-abutment/implant interface

offers striking similarities, some differences should be
considered.
To assess the PD or the CAL, the clinician should refer a
fixed reference point and follow this over time but
contrary to the natural dentition; the cementoenamel
junction absent in implant.

45
 Absence of the PDL surrounding implant means
that no resilient connection exists between teeth
and jawbone, and thus any occlusal disharmony
will have repercussions at the bone-to-implant
interface.

No intrusion or migration of teeth can compensate

for the eventual presence of a premature contact
on implant. So it will directly affect the bone.

46
 The lack of a PDL also means that the clinician
should be reluctant to use oral implants in
growing individuals. The neighboring teeth with
periodontal tissues will further erupt, leading to
occlusal disharmonies
Even it is problematic to place one or more
implants in a location surrounded by teeth that are
very mobile due to loss of periodontal support,
because as the teeth move away from the occlusal
forces, the implant(s) will bear the entire load.

47
 The tactile sensations will be reduced in the
patients having implants because of absence of
PDL, so patients should be instructed about food
intake in early healing period.

Considering the reduced tactile sensation

especially during the first months, the restorative
dentist should not rely on the patient's subjective
perception when checking the occlusion.

48
 Factors influencing
osseointegration
Osseointegration is a union between bone and the
implant surface and can be measured
histologically as the proportion of the total implant
surface that is in direct contact with bone.
implant material & design
host factors
surgical technique

49
 1.IMPLANT DESIGN
Implant design has a great influence on the stability and
subsequent function of the implant in bone.
Root-form implants, such as screws and cylinders, are the
dominating implant designs today.
Screw implants are considered to be superior to cylindrical
ones in terms of initial stability and resistance to
compression and tension stresses under loading.
Factors related to implant design are

50
 Implant Length

shorter implants fail more often than longer

implants.
Implant length varies from 6-20mm.
The most common lengths employed are
between 8- 15mm.
Always best to use the longest implant that
can be safely placed, with, wherever
possible bicortical stability
51
 Implant Diameters

falls within the range of 3.3 to 6mm.

Narrow diameter implants-in small spaces.
Larger diameter implants - posterior areas
of the mouth and where there is poor
quality bone.

52
 Surface Characteristics
Machining - the surface is produced by precision
milling with no subsequent finishing.
Plasma-spraying - spraying with molten titanium
modifies and increases the effective surface area
of the implant.
Machine grit-blasting - the implant surface is
roughened by grit-blasting with titanium oxide
particles.

53
 Acid-etching - the implant surface is chemically
etched to increase the thickness of the oxide layer.
Sand-blasting and acid-etching sand-blasting
followed by acid-etching to substantially increase
surface area.
Anodisation - the implant surface is electrically
treated to increase the thickness of the oxide layer.
Coating - the implant surface is coated with CaP04
HA to produce a so-called bioactive surface to
enhance bone-to-implant contact.
54
 Implant biomaterials
Implant biomaterials are subjected to significant
scientific scrutiny before they can be used in vivo.
Various materials used are:
-Metals
-Ceramics, or ceramic coated implants
-Polymers
-Others

Most commonly used materials are metals.

55
 Most commonly used metal is titanium. As a result of
Branemarks extensive studies titanium has become the
gold standard in implant materials.

Reasons are:- low specific gravity with density of 45gm/m3

- High heat resistance
- High tensile strength compared to stainless steel
- Resistance to corrosion
- Oxides are very stable and resistant to corrosion.

56
 Various metals used for
implant preparation

Metals Composition
Most commonly used Commercially pure titanium
Titanium Alloys Ti-6Al- 4V & Ti-6Al-4 V Extra Low interstitial ( ELI)
Newer alloys are Ti-13Nb- 13Zr & Ti- 15Mo-2.8Nb
Stainless steel containing 18% chromium for corrosion resistance & 8%
nickel to stabilize its austenite structure.

Co-Cr-Mo cobalt 33%, Chromium 30%, & Molybdenum 5%

Vitallium was introduced in late 1930 and is part of the Co-
Cr-Mo family

57
Ceramic & ceramic-coated implant system

Various ceramic implants are:-

-Al2O3 Aluminium oxide
-Zirconia (ZrO2)
-Hydroxyapatite & Tri-calcium phosphate
-Bioactive Glasses (SiO2-CaO-Na2O)

58
Polymers
PMMA and PTFE are the two commonly used
polymers for implant preparation.
The low mechanical strength of the polymer has
precluded their use as implant materials
The use of polymer in osseointegrated implants is
now confined to the implant components as
internal shock absorber in IMZ implant system.

59
Other Materials
Carbon & Carbon compounds like Vitreous
Carbon can be used for implant preparation,
but because of their low physical properties
the use is limited.

60
 2. HOST FACTORS

Bone Factors
Bone density has been found to be an
important factor in the initial stability and
prevention of micromovement of the
implant
Sectional tomograms and computed
tomography scans provide an indication of
medullary bone density.
61
 the quality of bone can be assessed during surgery,
based on subjective feel and by assessing cutting
resistance during drilling, tapping and placement
of the implant.
General Health
patients with a variety of systemic conditions may
be successfully treated with dental implants. As
with all patients undergoing a surgical procedure,
advice may be required from the patient's
physician.
62
 Age
Implant placement is not recommended in young
patients prior to completion of growth as the
implants may end up in infraocclusion. It is widely
recommended to wait until the patient is at least
17 to 18 years old.
Although wound-healing in the elderly is slower
than in young individuals, given reduced local
vascularity and bone density, there is no upper age
limit to implant placement, as long as the patient is
fit and able to undergo the necessary surgery.
63
 Smoking
well-established risk to general health and a factor
in periodontitis.
systemic vasoconstriction, reduced blood flow and
increased platelet aggregation.
So dental implants have approximately twice the
failure rate in smokers compared to non-smokers.
All implant patients should be encouraged to stop
smoking or to at least stop smoking for several
weeks before and after the surgical placement of
implants.
64
 Radiotherapy
results in endarteritis with impaired bone-
healing.
Success rates of dental implants are lower
in patients with a history of radiotherapy
compared to non-irradiated patients.
should be referred to specialist centers,
which may be able to provide, for example,
HBO therapy to improve the chance of
success.
65
 3. SURGICAL TECHNIQUE

Surgical Experience
Clinical experience and surgical skill have
been shown to have an impact on implant
success rates.
It is therefore imperative that those wishing
to place implants receive sufficient training
to become competent in all relevant pro
cedures.
66
 Operating Conditions
Contamination of the implant surface
during surgical placement should be
avoided.
Possible sources of contamination from
non-titanium surgical instruments and the
patient's saliva will, in all probability, have
a negative effect on osseointegration.
67
 Drilling Technique
Frictional heat during any phase of the
drilling procedure is detrimental.
The critical temperature is around 47C for
one minute.
The generation of heat can be kept to a
minimum by the use of sharp drills, slow
drill speeds, graduated drill sizes and
copious water-cooling.
68
 Healing and Loading Times
The time from implant insertion to
functional loading may be classified into
the following categories:
delayed loading four to six months
early loading one to two months
immediate loading.

69
 Delayed loading

this tried and tested approach involves the

implant not being loaded following
placement until approximately
6 months - maxilla
4 months - mandible.
The difference in timing is primarily related
to the difference in bone quality between
the maxilla and mandible.
70
 Early loading

a number of implant systems with

roughened thread designs are considered to
be appropriate for early loading within six
weeks of implant placement.
Such implants should only be placed in
good quality bone and under favorable
circumstances.

71
 Immediate loading

in exceptional cases it has been suggested

that it may be possible to consider the
immediate loading of implants.
Factors such as initial implant fit, quality
and quantity of available bone, length and
diameter of implant, occlusal factors and
experience of the operator should be taken

72
 Components of Dental
Implants
Today the most commonly used implant
design is the endosteal root form implants.

A generic language for the endosteal

implants was developed by Mish & Mish in
the year 1992.

73
 Basically the implant systems are classified in
two:
-one-piece implant system - abutment is already
fixed to implant body
- two-piece implant system - implant body and
abutments are two different parts

74
Implant body:
It is that part of the implant which is placed inside
the bone, and which forms the basic foundation of
implant supported prosthesis.
Types: Cylinder,
Screw,
Combination

75
 Cylinder (press-fit) root form
They can be parallel wall or tapered design.
Are usually pushed or tapped into a prepared bone
site.
It depends upon coating or surface condition to
provide microscopic retention to the bone.
Most often coating is rough material (HA, TPS) or
a macro retentive design (eg. Sintered ball).

76
77
 Screw root forms
Are threaded into the prepared hole which is
slightly smaller than implants diameter, thus have
macroscopic retentive feature.
They may be machined, textured, or coated.
There are three basic screw-thread geometries: V-
thread, buttress or reverse buttress thread, &
power (square) thread design.
Also available in parallel or tapered form.

78
 Thread design

V-thread Buttress thread

Reverse Buttress thread

Power or Square thread

79
Force distribution pattern as per thread shape

80
 Crestal antirotational features of implant

External Hex Internal Hex

81
Implant body parts
coronal antirotational feature
hex
Crestal portion
crestal module
-Transosteal portion
-has surgical,
biologic width, loading
Prosthetic influence

Body/Coronal 2/3rd have parallel walls for

stability and surgical
simplicity.

Apical taper along with flat surface

Apical1/3rd -For anatomical limitations.
-Eases surgical placement
-Flat surface as apical antirotational feature

82
 Combination root form

It has feature of both cylinder & screw root

form implants.
These design also may benefit from
microscopic retention to bone through
varied surface treatments.

83
 First stage cover screw

It is that portion which covers the implant

body after initial surgical procedure, to
prevent blood clots, epithelium, connective
tissue and bone to grow inside the implant
body.

84
 Second stage per-mucosal
extension or healing abutment

After initial healing period the first stage

cover screw is replaced with healing
abutment which helps in the formation of
proper soft tissue contour around the final
prosthesis

85
 Abutments

It is intermediary part of implant system

which fixes the implant body to the
overlying prosthesis.
different designs, as per mode of the
fixation of the superstructure i.e. for
screw retention, for cement retention, for
mechanical attachment (Ball attachment).
Each of the three abutments are further
classified as straight or angled,
describing the axial relationship. 86
 Abutment for screw retention is used for a
screw retained bar or fixed prosthesis.
Abutment for cement retention may be one
piece or two piece, which are retained by
separate abutment screw.
Abutment for attachment are removable
prosthesis that are implant retained.

87
88
Hygiene module
It is to be used for the screw retention type
abutment for maintaining hygiene till the final
prosthesis is fixed to it.

Transfer coping
It is the part of implant system which helps in
transferring the exact position of implant as in the
bone to the impression and subsequently to the
lab.
89
Analog
It used in the fabrication of the master cast to
replicate the retentive portion of implant body or
abutment.
It is of two types the implant body analog which
goes inside the final cast and the implant
abutment analog which projects out of the cast.
After the master impression is obtained the
corresponding analog is attached to transfer
coping, and assembly is poured.
90
Coping
A prosthetic coping is a thin covering usually
designed to fit the implant abutment for screw
retention.
It serves as the connection between the abutment
and the superstructure.

Prosthesis screw
It is the component used to fix the final
superstructure or the prosthesis to the abutment.

91
92
 Clinical aspects of patient for
Dental Implants
Thorough clinical examination should be
done
If the candidate has good to favourable
systemic health the other factors should be
considered.
In the intra-oral examination oral hygiene
status, periodontal status, alignment of teeth,
force factors of the patient like bruxism or
clenching habits, should be evaluated.
93
 Local examination of the implant site
involves evaluation of adequacy of the
ridge in width and height, angulation of the
ridge & teeth, approximation of the vital
structures as like blood vessels, nerves,
sinus, soft tissue condition & length of
edentulous span.

94
 Bone condition is evaluated by various imaging
aids.
Standard projections
Periapical radiograph
Occlusal radiograph
Panoramic radiograph
Lateral Cephalometric radiograph
Complex imaging
Conventional X-ray tomography
Computed tomography
Cone-beam Computed tomography

95
 Bone density
Available bone is particularly important in
implant dentistry & is one of the key factors in the
success of the implant.
Quality of bone is dependent on systemic as well
as the functional factors.
In jaws quality of bone is often dependent upon
the arch position.
The more denser the bone, more the stability of
implant and better the long term prognosis.

96
 MacMillan and Parfitt (1926, 1962) have
reported on the structural characteristics and
variation of trabeculae in the alveolar regions of
the jaws
The mandible as an independent structure is
considered to be a force absorption unit.
Therefore when the teeth are present the outer
cortical bone is denser & thicker and the
trabecular bone is more coarse and dense.
97
 The maxilla is a force-distribution unit
Any strain to the maxilla is transferred by
the zygomatic arch and palate away from
the brain and orbit.
As a consequence, the maxilla has a thin
cortical plate and fine trabecular bone
supporting the teeth.

98
 BONE CLASSIFICATION SCHEMES
RELATED TO IMPLANT DENTISTRY

Linkow, in 1970, classified bone density into three

categories:

Class 1: The bone type consists of evenly spaced

trabeculae with small cancellated spaces- most ideal
Class 2 : The bone has slightly larger cancellated spaces
with less uniformity of the osseous pattern- satisfactory
Class 3 : Large marrow-filled spaces exist between bone
trabeculae- loose-fitting implant

99
 In 1985, Lekholm and Zarb listed four bone
qualities found in the anterior regions of the
jawbone.

100
 In 1988, Misch proposed four bone density
groups independent of the regions of the
jaws, based on macroscopic cortical and
trabecular bone characteristics.
The bone density may be determined by
tactile sense during surgery, the general
location, or radiographic evaluation.

101
 Mish bone density classification
Bone Description Tactile analog Typical anatomical
density location
D1 Dense cortical Oak or Maple Anterior mandible
wood

D2 Porous cortical White pine or Anterior mandible

& coarse spruce wood Posterior mandible
trabecular Anterior maxilla

D3 Porous cortical Balsa wood Anterior maxilla

& fine Posterior maxilla
trabecular
D4 Fine trabecular Styroform Posterior maxilla

102
 Usual anatomic location of bone density types
(% occurrence)

Bone Anterior Posterior Anterior Posterior

maxilla maxilla mandible mandible
D1 0 0 6 3
D2 25 10 66 50
D3 65 50 25 46
D4 10 40 3 1

103
Radiographic bone density
Radiographs are not very beneficial to determine bone
density, because the lateral cortical plates often obscure
the trabecular bone density.
More precisely determined by tomographic radiographs,
especially computerized tomograms
Each pixel has a CT number (Hounsfield unit) related to
the density of the tissues within the pixel.
In general higher the CT number, the denser the tissue

104
 Accordingly bone density has been
classified as per the Hounsfield units as
follows
Density Hounsfield unit
D1 1250
D2 850 TO 1250
D3 350 TO 850
D4 150 TO 350
D5 150

105
 As per the various studies the bone strength,
elastic modulus, bone-implant contact &
stress transfer will be most favourable in the
denser bone, which ultimately increases the
long term success of the implants
These are the main factors which form the
basis for the treatment plan modification.

106
Dimensions Of Ridge - The Ideal
Requirements

The factors to be considered for the evaluation of

available bone for implant are:
-height,
-width,
-length,
-angulation &
-the crown height space.

107
Alveolar Bone
There should be sufficient width and space for successful
implant placement.
Assuming a regular size implant that is 4 mm in diameter and 10
mm long,
the minimal width - 6 to 7 mm,
minimal height - 10 mm (minimum of 12 mm in the posterior
mandible, where an additional margin of safety
required over the mandibular nerve)
This dimension is desired to maintain at least 1.0 to 1.5 mm of
bone around all surfaces of the implant after preparation and
placement.

108
Interdental Space
Implant should be minimum 1.5mm away
from adjacent structures like crown, &
roots.
Considering this factors the minimum I/D
space for a 4mm implant in single
edentulous space is 7mm (1.5 + 4 + 1.5 =
7).
109
110
 In this case if two teeth are missing and it s
planned to place 2 implants minimum space
required is 14mm.
(1.5+4+1.5+1.5+4+1.5=14)
The required minimal dimensions will
increase or decrease according to the size of
the implant.

111
 Whenever space between teeth is greater
than 7 mm and less than 14 mm, only one
implant, such as a wide-diameter implant,
should be considered.
Or in this case 2 narrow diameter implants
can be considered keeping 1.5mm space
around each implant.
However, the smaller implants may be more
vulnerable to implant fracture.
112
 Interocclusal Space

The superstructure of implant consists of the

abutment, the abutment screw, and the crown.
This is called as the restorative stack.
The dimensions of the restorative stack vary
slightly depending on the type of abutment and the
implant-restorative interface (i.e., internal or
external connection).

113
 In any of such situations the minimum amount of
interocclusal space required for the restorative
"stack" on an implant is 7 mm.

114
 1985, Misch and Judy established four basic
divisions of available bone for implant dentistry
and determined different implant approach for
each category.
The angulation of bone and crown height space
were also included for each bone volume, because
they affect the prosthetic treatment.
These original four divisions of bone were further
expanded with two subcategories to provide an
organized approach to implant treatment options
for surgery, bone grafting, and prosthodontics. 115
 Divisions are:
Division A (Abundant Bone)
Division B (Barely Sufficient Bone)
Division C (Compromised Bone)
Division D (Deficient Bone)

116
 Division A (Abundant Bone)

Width > 6 mm
Height > 12 mm
Mesiodistal length > 7 mm
Angulation of occlusal load (between occlusal plane
and implant body) < 25 degrees
Crown height space < 15 mm

117
 Division B (Barely Sufficient
Bone)
2.5 to 6mm wide
B+: 4 to 6mm
Bw: 2.5 to 4mm
Height: > 12 mm
Mesiodistal length > 6 mm
Angulation of occlusal load (between occlusal
plane and implant body) < 20 degrees
Crown height space < 15 mm

118
 Division C (Compromised
Bone)
The Division C ridge is deficient in one or more
dimensions (width, length, height, or angulation).
Dimensions are
Width (C-w bone): 0 to 2.5 mm
Height (C-h bone) < 12 mm
Angulation of occlusal load (C-a bone) > 30 degrees
Crown height space (CHS) > 15 mm

119
 Division D (Deficient Bone)

Long-term bone resorption may result in the complete loss

of the residual ridge, accompanied by basal bone atrophy
Parameters are
Severe atrophy
Basal bone loss
Flat maxilla
Pencil-thin mandible
>20 mm crown height

120
 The completely edentulous Division D patient is
the most difficult to treat in implant dentistry.
Benefits must be carefully weighed against the
risks.
If implant failure occurs, the patient may become
a dental cripple i.e. unable to wear any prosthesis

121
 Implant biomechanics

Biomechanics forms the one of the most important factor

for the implant success after its placement.
Forces if not well balanced will lead to excessive stress
concentration and the implant failure.
So there should be properly designed implant system in
relation to key implant positions, implant number, and
implant design after the bone factors have been
determined.

122
Key Implant Positions

Some implant positions are more critical than

others in regard to force distributions.
There are four general guidelines to determine key
implant positions:
No cantilevers
No three adjacent pontics
Canine-molar rule
Arch Dynamics

123
No cantilevers
Cantilevers are force magnifiers to the implants,
abutment screws, cement or prosthesis screws, and
implant-bone interface.
Usually cantilevers acts as Class 1 lever
The length of the cantilever is directly related to the
amount of the additional force placed on the abutments of
the prosthesis.
As implants are devoid of PDL these additional forces are
more detrimental for implants than for teeth.

124
 So the cantilevers on the prosthesis should be
reduced and preferably eliminated.
Therefore the terminal abutments in the prosthesis
are key positions.

125
No three adjacent pontics
three adjacent pontics are contraindicated on implants,
just as they are contraindicated on natural abutments.
The greater the span between abutments, the greater is the
flexibility of the metal in the prosthesis.
This flexure forces places shear and tensile forces on the
abutment.
As implants are more rigid, because of lack of stress
absorber mechanism (PDL) of natural teeth, such forces
are more detrimental on it.

126
 Therefore as because three posterior pontics are
contraindicated in a natural tooth-fixed prosthesis, it is
even more important not to have three pontics in an
implant restoration

127
 The span of the pontics in the ideal treatment plan
should be limited to the size of two premolars,
which is 13.5 to 16 mm.
Therefore in case of molar when the span is
greater than 14 mm, two pontics should be
considered to replace the tooth.
As a result, when a second premolar and first
molar are missing this span is often treatment-
planned to replace three teeth, rather than two.

128
129
Canine & first molar rule
A fixed restoration replacing a canine is at greater risk
than nearly any other restoration in the mouth.
Lateral incisor is a weakest anterior & first premolar is
the weakest posterior tooth in oral cavity.
A traditional fixed prosthetic axiom indicates it is
contraindicated to replace a canine and two or more
adjacent teeth.

130
 Therefore if a patient desires a fixed prosthesis,
implants are required whenever the following
adjacent teeth are missing in either arch:
(1) the first premolar, canine, and lateral incisor;
(2) the second premolar, first premolar; and
canine; and
(3) the canine, lateral and central incisors.

131
 Whenever these combinations of teeth are missing,
implants are required for restoration because:
(1) the length of the span is three adjacent teeth,
(2)the lateral direction of force during mandibular
excursions increase the stress, and
(3) the magnitude of the bite force is increased in the
canine region compared to anterior region.
Therefore in these conditions at least two key implants
are required to replace these adjacent teeth one of
which should always be canine.
132
 The first molar is also a key implant position when
three adjacent posterior teeth are missing.
Because the bite force doubles in the molar
position compared with the premolar position in
both jaws.

133
Key arch position
An arch may be divided into five segments, similar to an
open pentagon.
The two central and two lateral incisors form one
segment.
Individual canines on both sides form one segment each
and molars and premolars on both sides form a segment.

134
 Anterior segment
Canines

Molar-premolar s
segment

135
 However when two or more segments of an arch
are connected, the tripod effect is greater and, as a
benefit, an A-P spread is created from the most
distal terminal abutments to the most anterior pier
abutment.
When multiple adjacent missing teeth extend
beyond one of the open pentagon segments, a key
implant position needs to be situated within each
segment.

136
 Therefore if the patient is edentulous from first
premolar to first premolar the key implant
positions include the terminal abutments (the two
first premolars), the two canines, and either of the
central incisor positions .
These implant positions follow the rules of:
(1) no cantilever,
(2) no three adjacent pontics,
(3) the canine position, and
(4) at least one implant in each edentulous segment
of an arch. 137
138
Implant number
Key implant positions are often not enough to support the
restoration, unless all patients force factors are within
normal range.
Most often additional implants (besides the key implants)
are added to the treatment plan
Decision on the number of implants in the treatment plan
begins with the implants in the ideal key positions
Additional numbers are most often required, and
primarily related to the patient force factors or to bone
density in the edentulous sites.

139
 Patient who bruxes severely will require one
implant for each missing root (two implants for
each molar).
Likewise, patients with moderate force factors and
poor bone density may also require one implants
per missing root.
Other factors to be considered for implant number
is the available MD space.

140
 Implant body size: a
biomechanical and Esthetic
Rationale
Dental implants function to transfer loads to
surrounding tissues.
Forces on dental implants may be characterized in
terms of: magnitude, duration, type, direction, and
magnification.

141
 to reduce stress, either the force must
decrease or the surface area must increase.
An increase in implant size is beneficial
option to decrease the stress applied to the
system as patient force factors can not be
effectively managed.
The size of an implant may be modified in
either length or diameter

142
Implant length
The length of the implant is directly related to the overall
implant surface area.
As a result, a common axiom has been to place an
implant as long as possible.
The higher the forces or softer the bone the greater the
implant body length and diameter suggested.
But in situation where the anatomical factors are not
modifiable the shorter length implant is the option.

143
Implant diameter
After possible implant length has been selected the
diameter plays a role in modifying the surface area.
It is said that each mm increase in the diameter of the
implant increases the surface area by 30% to 200%
depending on the type of implant like cylinder versus
threaded.
For each mm increase in the length the surface area
increases by 10% to 20%, which is less as compared to
seen with diameter.

144
 So implant diameter has the more important role
in surface area than its length and ultimately in
counteracting the effect of functional forces on the
implants.
So whenever possible the best possible wide
diameter implants should be used.

145
 The wide-diameter implant presents various advantages
like loading (Biomechanical), surgical and prosthetic
advantages.

Various loading advantages are as follows:

Increase surface area
Compensate unfavorable patient force factors
Minimize cantilevers for angled implant
Compensate for poor bone density
Enhance surface area for short implants

146
 Various surgical advantages are:
Surgical rescue implant
Failed implant/immediate
Tooth extraction/immediate

147
 Various prosthetic advantages are:
Improve emergence profile
Decrease screw loosening
Minimize component fracture
Facilitate oral hygiene

148
 Disadvantages of wide diameter implants:
-Bone trauma in drill sequence
-Decreased facial or lingual bone thickness
leads to recession
-Increased surgical failure rates
-Too close to adjacent tooth, & PDL
encroachment

149
 Guidelines for implant dimension
selection
Natural teeth
The natural tooth roots may serve as an indicator for
implant width requirements for prosthetic loads.
The correlation is most likely found because of the
biomechanical relationship of the amount and type of the
forces and the type of the root morphology & bone in that
region.
mandibular incisors, 3- to 3.5-mm diameter implants;
maxillary lateral incisors
maxillary anteriors, 4-mm diameter implants
premolars in both arches,
mandibular canine
molars 5- or 6-mm-diameter implants or
two 4mm diameter implants
150
Implant size based on esthetic
Anterior tooth replacement
Two conditions determine the ideal anterior tooth implant
size in the mesiodistal dimension.
First - The ideal diameter most often corresponds to the
width of the missing natural tooth, 2 mm below the CEJ.
Second - the implant diameter plus 1.5 mm on each side
should be equal to or less than the mesiodistal dimension
between the two natural roots at the level of the crest of
the residual ridge.

151
Multiple anterior implants
A minimum distance of 3 mm is suggested especially
when crestal bone loss is expected around the implants,
to accommodate for eventual crestal bone loss and
maintain interseptal bone levels.
size dimension of two adjacent anterior implants should
most often be reduced compared with the ideal
dimensions of a single-tooth implant
This helps to increase the amount of bone facially,
increase the amount of soft tissue interdentally and
decrease the risk of esthetic complications.
152
Posterior tooth replacement
The ideal implant size in the posterior maxilla
depends on four criteria:
The implant dimension should correspond to the natural
tooth (2 mm below the CEJ).
The implant should be at least 1.5 mm from the adjacent
teeth.
The implant should be at least 3 mm from an adjacent
implant.
The implant should be at least 4 mm in diameter.
153
 These criteria provide the better implant design for
long term success.
But when the diameters of molar implants do not
provide sufficient surface area, the number of
implants should be increased.
When multiple adjacent posterior teeth are
missing, increasing the number of implants affects
the overall surface area than the implant size.

154
 GENERAL PRINCIPLES OF
IMPLANT SURGERY
The basic surgical principles for the implant surgery
are proper pre-operative patient care, maintenance
of aseptic field, following gentle atraumatic
surgical procedure, and proper post-operative care.
to achieve osseointegration:
1. Implant must be sterile and made up of
biocompatible material.
2. Implant site preparation should be done under
sterile condition.

155
3.Implant site preparation should be done under
atraumatic surgical technique that avoids overheating
of the bone during preparation of the recipient site

4. Implants should be placed with good initial stability.

5.Implants should be allowed to heal without loading or

micromovement (i.e. undisturbed healing period to
allow for osseointegration) for 2 to 4 months and 4 to 6
months in the mandible and maxilla, respectively.
156
 Components of the implant
kits
1. Pilot hole drills
2. Osteotomy Drills
3. Depth Gauges depth guides
4. Bone expanders
5. Implant drivers
6. Ratchet Wrench
7. Prosthetic drivers
8. Bone Collector
9. Sinus lift surgical instruments with special drills for that
procedure

157
Basic surgical methods for implant placement:
- One stage implant surgery
- Two stage implant surgery
In the one-stage approach implant or the abutment
emerges through the mucosa at the time of
placement,
In two-stage approach the top of the implant and
cover screw are completely covered with the flap
closure & implants are allowed to heal, without
loading or micromovement, for prescribed time
period. 158
One stage
abutment emerges through the mucosa top of the implant and cover screw are
at the time of implant placement
No need of second surgery
Adv:
Easier mucogingival management
Patient management is simplified
Two stage
completely covered with flap without
loading or micromovement, for
prescribed time period
Second surgery is done to expose the
implants
Adv:
Advantageous when simultaneous
bone grafting is necessary
Prevents mobility in initial healing
period
Prevents contamination of BI
interface.
159
 TWO-STAGE "SUBMERGED"
IMPLANT PLACEMENT

Basic surgical steps:

1. Flap design, Incision, and Elevation
Flap management will vary depending on the
location and objective of the planned surgery.
Two types of incision used are crestal and remote
incisions.
Crestal incision is made on the crest of the ridge
bisecting the existing zone of keratinized mucosa.

160
 It is easier to manage and results in less bleeding,
less edema, and faster healing
Remote incision is made at some distance from
the osteotomy site.
It is basically planed when extensive bone
augmentation is to be done.
A full-thickness flap is raised buccally and
lingually to the level of the mucogingival
junction.

161
 The bone at the implant site(s) must be
thoroughly debrided of all granulation
tissue.
For a "knife-edge" alveolar process if
sufficient height is available osteoplasty is
done to get proper bone contour, otherwise
the bone augmentation is planned

162
2. Implant Site Preparation
After proper flap reflection the implant site
is prepared with a sequence of drills.
A surgical guide or stent is used for locating
exact position and used throughout the
procedure to direct the proper implant
placement.

163
Drilling sequence is as follows:

Round bur
2-mm twist drill
Pilot drill
3-mm twist drill
Countersink drill
Bone Tap (optional)
Implant placement

164
Round bur
It is first used to mark the implant sites.
With the help of guide/stent the initial marks are
checked for their appropriate location, as well as
the positions relative to each other.
Each marked site is then prepared to a depth of 1
to 2 mm with a round drill, breaking through the
cortical bone and creating a starting point for the
2-mm twist drill

165
166
2-mm Twist Drill
to establish the final depth and to align the long
axis of the implant.
should be properly irrigated with to control the
overheating
to be used at the rpm of 800 to 1200.
drills should be intermittently and repeatedly
"pumped" or pulled out of the osteotomy sites
while drilling to expose them to the water coolant
and to facilitate clearing bone debris from the
cutting surfaces.
167
 Twist drill (2 mm): Has 2 mm diameter & is available in
different lengths 7, 10, 15, 20 mm.

168
 When multiple implants are being placed next to
one another, a guide pin should be placed in the
prepared sites to check alignment and parallelism
throughout the preparation process.
The relationship to neighboring vital structures
can be determined by taking a periapical
radiograph with a guide pin or radiographic
marker in the osteotomy site.
The next step is to use the series of drills to widen
the osteotomy size to accommodate the required
implant. 169
 Direction indicator: Double ended instrument
used to check parallelism during drilling
procedures.

170
 Depth gauge : Graduated end is used to measure depth of
fixture sites & opposite end to measure distance between
adjacent fixture sites.

171
Pilot Drill
Following the 2-mm twist drill, a pilot drill with a
non-cutting 2mm diameter "guide" at the apical
end and a cutting 3mm diameter (wider)
midsection is used to enlarge the osteotomy site,
thus facilitating the insertion of the subsequent
drill in the sequence.

172
 Pilot drill : Used after using 2 mm twist drill to enlarge
fixture site 2 to 3 mm & makes use of 3 mm twist drill
easier.

173
The 3-mm Twist Drill
The final drill in the preparation of a standard-diameter
(4.0-mm) implant is the 3-mm twist drill.
It is used to widen the site along the entire depth of the
osteotomy from 2 to 3 mm.
This final drill in the sequence will finish cutting the
osteotomy site and will help the clinician determine
whether the implant will be stable or not
It is important that the final-diameter drilling be
accomplished with a steady hand, without wobbling .

174
 Twist drill (3mm) : Used after pilot drills to
enlarge fixture site.

175
Countersink Drill (Optional)
countersink drilling is used to shape or flare the
crestal aspect of the osteotomy site, helps in
placing the cover screw at the level or slightly
under bone crest.

176
177
Bone Tap (Optional)
It is to create threads in the osteotomy site.
It is needed for the placement of threaded implants.
With self-tapping implants becoming almost universal,
there is less need for a tapping procedure.
Is used in dense cortical bone where long implants are
used to facilitate implant insertion and to reduce the risk
of implant binding.
When faced with a very soft, poor-quality bone (e.g., loose
trabecular bone in the posterior maxilla), tapping is not necessary
or recommended

178
179
 Bone tapping and implant insertion are both done
at very slow speeds (e.g., 25-30 rpm).
All other drills in the sequence are used at higher
speeds (800-1200 rpm).
It is important to create a recipient site accurately
in size and angulation. Slight variation may also
affect the long term survival of the implant.
With wide-diameter drills it is advisable to reduce
the drilling speed (e.g., to 500-600 rpm),
according to the manufacturer's guidelines, to
prevent overheating the bone.
180
Implant placement
Implants are inserted with a handpiece rotating at slow
speeds (e.g., 25 rpm) or by hand with a wrench.
Insertion of the implant must follow the same path or line
as the osteotomy site.
When multiple implants are being placed, it is helpful to
use guide pins.
the implant is placed flush with the bone crest, and the
soft tissue covering is purposely kept thick to minimize
the risk of premature exposure of the cover screws

181
Flap Closure and Suturing
Once the implants are inserted and the cover
screws secured, the surgical sites should be
thoroughly irrigated with sterile saline.
One of the most important aspects of flap
management is achieving good primary closure of
the flap that is tension free.
This is achieved by incising the periosteum.

182
 For patient management, it is sometimes
simpler to use a resorbable suture
However, when moderate to severe
postoperative swelling is anticipated, a non-
resorbable suture is recommended to
maintain a longer closure period
The sutures are removed in postoperative
period of 7 to 10 days
183
Postoperative Care
Proper instructions of wound care.
Antibiotics & analgesics should be given.

184
Second-Stage Exposure Surgery
The objectives for the second surgery are as follows:
-To expose the submerged implant without damaging the
surrounding bone for placing the healing abutment.
-To control the thickness of the soft tissue surrounding
the implant.
-To preserve or create attached keratinized tissue around
the implant.
-To facilitate oral hygiene.
-To ensure proper abutment seating.

185
 Simple Circular "Punch" Incision is used in the
areas with sufficient zone of keratinized gingiva to
uncover the head of the implant
Alternatively crestal incision can be used.
In the cases with insufficient width of keratinized
gingiva the surgeries are done to widen the zone
of attached gingiva.
After these surgical procedures again the
postoperative care should given.

186
 ONE-STAGE "NON-SUBMERGED"
IMPLANT PLACEMENT
In the two-stage surgical approach, the implant is placed
flush with the bone crest.
In the one-stage surgical approach, the implant or the
healing abutment protrudes about 2 to 3 mm from the
bone crest, and the flaps are adapted around it.
In posterior areas of the mouth, the flap is thinned and
sometimes sutured apically to periosteum to increase the
zone of keratinized attached gingiva around the implant

187
ONE STAGE IMPLANT TWO STAGE IMPLANT

188
Basic surgical procedure:
Flap Design, Incisions, and Elevation
The initial incision in the flap design for this
technique is always a crestal incision bisecting the
existing keratinized tissue.
Vertical incisions may be needed at one or both
ends.
Facial and lingual flaps in posterior areas should
be carefully thinned before total reflection to
minimize the soft tissue thickness.
Full-thickness flaps are elevated facially and
lingually.
189
Implant Site Preparation
The implant site preparation is identical in
principle to the two-stage implant surgical
approach.
The primary difference is that the implant
or the healing abutment extension of the
implant is placed in such a way that the
head of the implant protrudes about 2 to 3
mm from the bone crest.
190
Flap Closure and Suturing
The keratinized edges of the flap are sutured with
single interrupted sutures around the implant.
When keratinized tissue is abundant, scalloping
around the implant(s) provides better flap
adaptation.

191
Advanced implant surgical procedures are:

Maxillary sinus elevation and bone

augmentation.
Supracrestal bone augmentation.

192
 Clinical success of dental
implants
There have been several long-standing debates
about what is considered successful in implant
dentistry.
The most frequently cited success criteria are
those by Schnitman and Schulman (1979) and by
Albrektsson et al (1986).

193
Albrektssons criterias (1986):
1. The individual, unattached implant is immobile
when tested clinically.
2. The radiograph does not demonstrate any
evidence of periapical radiolucency.
3. Vertical bone loss should be less than 0.2 mm
annually following the implant's first year of
service.

194
4. Individual implant performance must be
characterized by an absence of signs and
symptoms such as pain, infections, neuropathies,
paresthesia, or violation of the mandibular canal.
5. Success rates of 85% or more at the end of a 5-
year observation period and 80% at the end of a
10-year period are the minimum criteria for
success.

195
 Smith and Zarb (1989) modified Albrektsson's criteria by
stating that the patient's and dentist's satisfaction with the
implant prosthesis should be the primary consideration
and that aesthetic requirements should be met.
Although these criteria have become more stringent in
recent years, measurement of success in implant
dentistry is still difficult to quantify.
It is important that standardized criteria for success be
established to enable proper evaluation and evolution of
implant dentistry.

196
 Complications Related To
Implants
Complications may be grouped as:
Surgical complication:
1. Hemorrhage & Hematoma
2. Neurosensory Disturbances
3. Damage to adjacent teeth

197
2. Biologic complication:
-Soft tissue Inflammation & Proliferation
-Dehiscence & Recession
-Peri-implantitis & Bone loss
-Implant loss or Failure

198
3. Technical or mechanical complication:
- Screw loosening or Fracture
- Implant fracture
- Fracture of restorative material

4. Esthetic & Phonetic complications

199
 Endosteal dental implants are successful
and predictable.
Complications and failures are less but the
significant factor.
The key to avoid the complications is to
understand the causes of complications and
plan the treatment accordingly.

200
 Conclusion
The goal of modern dentistry is to return the
patient to oral health in predictable fashion.
Implant prosthesis often offer a more
predictable treatment course than traditional
restorations.
Most patients whether missing the single tooth,
several teeth, or the complete teeth can be
candidate for implant therapy.
However many factors can influence the
treatment outcomes. 201
 Therefore it is essential to understand and
follow the basic guidelines to achieve the
successful treatment plan for the long term
benefit of the patient.

202
 References
Carranzas Clinical Periodontology, 10 th Edtn
Contemporary Implant Dentistry, Carl E. Mish, 3 rd
Edtn.
Phillips, Science of Dental Materials, 11 th Edtn.

203
THANK YOU

204