DENTAL IMPLANTOLOGY

DEFINATION
DENTAL IMPLANT: DENTAL IMPLANT IS A PROSTHETIC DEVICE
MADE UP OF ALLOPLASTIC MATERIALS IMPLANTED INTO THE
ORAL TISSUES BENEATH THE MUCOSAL AND PERIOSTEAL
LAYER OR WITHIN THE BONE TO PROVIDE RETENTION AND
SUPPORT FOR A FIXED OR REMOVABLE DENTAL PROSTHESIS.
 HISTORY AND EVOLUTION
ANCIENT ERA : UPTO 1000 AD IMPLANTATION OF ANIMAL TEETH OR
TEETH CARVED OUT OF IVORY WAS PEROFRMED ON WOMEN IN A
ANCIENT EGYPTIAN DYNASTIES.
MEDIEVAL PERIOD: 1000-1799 TRANSPLANTATION OF TEETH WAS
POPULAR DURING THIS PERIOD AND LOST ITS POPULARITY DURING
BEGINNING OF 19TH CENTURY DUE TO TRANSFER OF DISEASES.
FOUNDATION PERIOD: 1800-1900 MAGGILIO PLACED GOLD IMPLANT
INTO FRESHLY EXTRACTED SOCKET.
PREMODERN ERA : 1910-1930 GREENFIELD USED A TWO PIECE
HOLLOW BASKET FABRICATION FROM SOLDERED WITH 24 KARAT GOLD.
MODERN ERA: 1935-1970 STORK DESCRIBED A MATHOD OF PLACING A
SCREW TYPE IMPLANT MADE OF VITALLIUM (COBALT – CHROMIUM – MO
LYBDENUM ALLOY).
1970: THE TERM “OSSEOINTEGRATION” WAS COINED BY BRANEMARK.
TODAY: PREDOMINANTLY OF TITANIUM AND FOR BETTER
OSSEOINTEGRATION, TITANIUM PLASMA SPRAYED COATING,
SANDBLASTING, SURFACE ETCHING OR HA(HYDROXYAPATITE) COATING.
INDICATION AND CONTRAINDICATION
INDICATION
ANY EDENTULOUS SPACE
CONTRAINDICATION
UNCONTROLLED DIABETES MELLITUS
SMOKING
ACUTE BONE RESORPTION
POOR PATIENT ACCEPTANCE
RADIATION LESS THAN 1 YEAR BEFORE IMPLANT PLACEMENT
 ADVANTAGES AND DISADVANTAGES
ADVANTAG
• PROVIDE SUPPORT FOR A DENTURE, MAKING IT MORE
SECURE AND CONFORTABLE.
• USED FOR ANCHORAGE DURING ORTHODONTIC TREATMENT.
• TEETH CAN BE POSITIONED FOR AESTHETICS.
• OCCLUSION AND IMPROVED MASTICATION.
DISADVANTAGE
• PROLONGED TRAETMENT DURATION
• INVOLVES SURGICAL PROCEDURE.
• EXPENSIVE.
 CLASSIFICATION OF IMPLANTS
BASED ON LOCATION AND DESIGN

ENDOSSEOUS TRANSOSSEOUS SUBPERIOSTEAL

 WHO IS THE CANDIDATE FOR DENTAL
IMPLANTS

• THE IDEAL CANDIDATE FOR A DENTAL IMPLANT IS IN GOOD GENERAL AND

ORAL HEALTH. ADEQUATE BONE IN YOUR JAW IS NEEDED TO SUPPORT THE
IMPLANT, AND THE BEST CANDIDATES HAVE HEALTHY GUM TISSUES THAT ARE
FREE OF PERIODONTAL DISEASE.

•GOOD BONE DENSITY

•PATIENCE: TAKE A LONG TIME TO HEAL AS LONG AS 6 MONTHS.

•NON SMOKERS
 THEORIES (BONE IMPLANT INTEGRATION)
• BRANEMARK’S OSSEOINTEGRATION THEORY: THE BONE IS LAID VERY CLOSE TO THE
IMPLANT WITHOUT ANY INTERVENING CONNECTIVE TISSUE. THE TITANIUM OXIDE
PERMANENTLY FUSES WITH THE BONE, AS BRANEMARK SHOWED IN 1950’S.
• WEISS’ THEORY OF FIBROSSEOUS INTEGRATION : THERE IS A FIBROSSEOUS LIGAMENT
FORMED BETWEEN THE IMPLANT AND THE BONE AND THIS LIGAMENT CAN BE
CONSIDERED AS THE EQUIVALENT OF THE PERIODONTAL LIGAMENT. HE DEFENDS THE
PRESENCE OF COLLAGEN FIBRES AT THE BONE IMPLANT INTERFACE. HE INTERPRETED IT
AS THE PERI-IMPLANTEAL LIGAMENT WITH AN OSSTEOGENIC EFFECTS.
STAGES OF BONE HEALING AND OSSEOINTEGRATION : CELL
KINETICS AND TISSUE REMODELLING
THE OSSEOINTEGRATION PROCESS OBSERVED AFTER IMPLANT INSERTION CAN
BE COMPARED TO BONE FRACTURE HEALING:-

• IN THE CASE OF A BONE FRACTURE, ANY BONE WOUND LEADS TO AN INFLAMMATORY

REACTION WITH BONE RESORPTION AND SUBSEQUENTLY THE ACTIVATION OF GROWTH
FACTORS AND ATTRACTION BY CHEMOTAXIS OF OSTEOPROGENITOR CELLS , FIBROBLAS
AND MESENCHYMAL CELLS MIGRATE AND FORMS GRANULATION TISSUE TO THE SITE OF
THE LESION. OSTEOBLAST AND FIBROLAST PROLIFERATES. THE DIFFERENTIATION
TOWARDS OSTEOBLASTS WILL LEAD TO A REPARATIVE BONE FORMATION. PRIMARY
CALLUS (FIBROBLASTS AND NEW BLOOD VESSELES) FORMS WITHIN 2 to 6 WEEKS. CALLUS
MAKE CARTILAGE AND IS MINERALIZED PRODUCING WOVEN OR LAMELLAR BONE.

•LOGICALLY, A CERTAIN IMMOBILITY SHOULD BE MAINTAINED. A MILD INFLAMMATORY

RESPONSE,AS TRIGERRED BY MOVEMENT MAY INHANCE THE BONE-HEALING RESPONSE,
BUT ABOVE A CERTAIN THRESHOLD, THIS IS DETRIMENTAL.

•IT HAS BEEN REPORTED THAT WHEN MICROMOVEMENTS AT THE INTERFACE EXCEEDS 150
micrometer ,DIFFERENTIATION TO OSTEOBLAST WILL NOT OCCUR; RATHER A FIBROUS
TISSUE LAID DOWN BETWEEN THE BONE AND THE IMPLANT SURFACE. OSSEO
INTEGRATION WILL BE COMPLETED WITHIN 8 WEEKS.
 HOW A NATRUAL TOOTH AND IMPLANT ATTACHES TO THE BONE.

FIBRES HOLDS TOOTH TO

THE BONE(PERIODONTAL
LIGAMENT),

WHILE THE BONE

ATTACHES DIRECTLY TO
IMPLANT CALLED
OSSEOINTEGRATION……….
 PATIENT EVALUATION
PRIOR TO PLLACEMENT OF IMPLANTS THE PATIENT SHOULD BE ASSESSED FOR:
• MEDICAL AND DENTAL HISTORY
• CLINICAL EXAMINATION
• RADIOGRAPHIC EXAMINATION: PREOPERATIVE IOPA AND ORTHOPANTO-
MOGRAM (OPG) REGARDING THE AVAILABLE BONE AND DISTANCE OF VITAL
STRUCTURES I.E. MAXILLARY SINUS, FLOOR OF NASAL CAVITY ,MANDIBULAR CANAL
FROM IMPLANT SITE.
• ALL VITAL SIGNS AND A COMPLETE HEMOGRAM
• COMPLETE ORAL PROPHYLAXIS BEFORE IMPLANT PLACEMENT
 ASSESSMENT OF BONE FOR IMPLANT PLACEMENT
1)BONE QUALITY INDEX S(LEKHOLM AND ZARB CLASSIFICATION)
2) BONE SHAPE (5 DEGREE SCALE 1-5)

TYPE-I : HOMOGENEOUS CORTICAL BONE.

TYPE-II : THICK CORTICAL BONE WITH MARROW CAVITY.
TYPE-III : THIN CORTICAL BONE WITH DENSE TRABECULAR BONE OF GOOD STRENGTH.
TYPI-IV : VERY THIN CORTICAL BONE WITH LOW DENSITY TRABECULAR BONE OF POOR
STRENGTH.
IN TYPE-IV BONE THE IMPLANT IS PLACED IN POOR QUALITY BONE WITH THIN
CORTEX AND LOW DENSITY TRABECULAE HAS A HIGHER CHANCE OF FAILURE
COMPARED WITH OTHER TYPES OF BONES.

THE LOW DENSITY BONE IS OFTEN FOUND IN POSTERIOR MAXILLA AND SEVERAL
STUDIES REPORT HIGHER IMPLANT FAILURE RATES IN THIS REGION.

THE HIGHER SURVIVAL RATE FOR DENTAL IMPLANTS IS IN THE MANDIBLE

PARTICULARLY IN THE ANTERIOR REGION OF MANDIBLE WHICH HAS BETTER
VOLUME AND DENSITY OF THE BONE.
 BONY CRITERIA FOR IMPLANT PLACEMENT
• BONE HEIGHT : MEASURED FROM CREST OF EDENTULOUS RIDGE TO THE
OPPOSING LANDMARKS. MINIMUM BONE HEIGHT- 10mm.
MINIMUM OF 2mm HEIGHT BETWEEN APEX OF IMPLANT AND
INFERIOR ALVEOLAR CANAL.

•
•BONE WIDTH: MEASURED BETWEEN FACIAL AND LINGUAL PLATES i.e, 0.5mm
BONE ON EACH SIDE OF IMPLANT AT THE CREST.

•BONE LENGTH: FOR BONE MORE THAN 5mm WIDTH, A MINIMUM

MESIODISTAL LENGTH OF 7mm IS SUFFICIENT. A WIDTH OF
BONE LESS THAN 5mm REQUIRES A 3.2mm IMPLANT WHICH
COMPROMISE LESS SURFACE AREA AND GREATER CRESTAL
CONCENTRATION OF STRESS.

•BONE ANGULATION:- THE INCISAL AND OCCLUSAL SURFACE OF THE TEETH FOLLOW
CURVE OF SPEE.
 COMPOSITION
• A TYPICAL IMPLANT CONSISTS OF A TITANIUM SCREW[RESEMBLE A
TOOTH ROOT] WITH A ROUGHENED OR SMOOTH SURFACE. THE MAJORITY
OF DENTAL IMPLANTS ARE MADE OUT OF COMMERCIALLY PURE
TITANIUM OR TITANIUM ALLOY Ti-6Al-4V , BETER TENSILE STRENGTH AND
FRACTURE RESISTANCE.. IMPLANT SURFACES MAY BE MODIFIED BY
PLASMA SPRAYING, ANODIZING, ETCHING OR SANBLASTING TO INCREASE
THE SURFACE AREA AND OSSEEOINTEGRATION POTENTIAL OF THE
IMPLANT
 SURGICAL PROCEDURE
• SURGICAL PLANNING
PRIOR TO SURGERY, CAREFUL AND DETAILED PLANNING IS
REQUIRED TO IDENTIFY VITAL STRUCTURES SUCH AS THE INFERIOR
ALVEOLAR NERVE OR THE SINUS, AS WELL AS THE SHAPE AND
DIMENSIONS OF THE BONE TO PROPERLY ORIENT THE IMPLANTS
FOR THE MOST PREDICTABLE OUTCOME. TWO-DIMENSIONAL
RADIOGRAPHS, SUCH AS ORTHOPANTO-MOGRAPHS OR
PERIAPICALS ARE OFTEN TAKEN PRIOR TO THE SURGERY.

SOMETIMES CT SCAN WILL ALSO BE OBTAINED.

A ‘STENT’ MAY SOMETIMES BE REQUIRED TO FACILITATE THE
PLACEMENT OF IMPLANTS. A SURGICAL STENT IS AN ACRYLIC
MOUTHPIECE THAT FITS IN YOUR MOUTH WITH PRE-DRILLED
HOLES TO SHOW THE POSITION AND ANGLE OF THE IMPLANTS
TO BE PLACED.
 BASIC PROCEDURE
ONCE THE FLAPS REFLECTED,BONE PREPARED,GRANULATION TISSUE REMOVED,KNIFE EDGE RIDGES
FLATTENED IMPLANT OSTEOTOMY SITE IS PREPARED BY A SERIES OF DRILLS:-

(A) A ROUND BUR FOR INITIAL MARKING,SURGICAL GUIDE IS REMOVED. EACH SITE TO A DEPTH OF
1-2 mm, CREATING START POINT FOR 2mm TWIST DRILL.

(B) USE OF 2mm TWIST DRILL TO ESTABLISH DEPTH AND ALIGN THE IMPLANT. AT A SPEED OF
800-1500 rpm WITH COUPIOUS IRRIGATION TO PREVENT OVERHEATING. DRILLS SHOULD
.
BE INTERMITTENTLY AND REPEATEDLY “PUMPED” OR PULLED OF THE OSTEOTOMY SITE WHILE
DRILLING TO EXPOSE THEM TO WATER COOLANT AND TO FACILITATE CLEARING OF BONE
DEBRIS. “CLINICIAN SHOULD PUMP THE DRILL( UP AND DOWN ) INTERMITTENTLY AND AVOID
PREPARING THE BONE WITH A UNIDIRECTIONAL “PUSH” OF THE DRILL IN THE APICAL
DIRECTIONAL ONLY.
(C) GUIDE PIN IS PLACED IN THE OSTEOTOMY SITE TO CONFIRM POSITION AND ANGULATION.
(D) PILOT DRILL IS USED TO INCREASE THE DIAMETER OF CORONAL ASPECT OF OSTEOTOMY
SITE.
(E) FINAL DRILL USED IS THE 3mm TWIST DRILL TO FINISH PREPARATION OF THE OSTEOTOMY
SITE.
(F) COUNTERSINK DRILL FOR CORONAL FLARE OF OSTEOTOMY SITE ALLOWING THE
CORONAL FLARE OF THE IMPLANT HEAD AND COVER SCREW TO FIT WITHIN THE
OSTEOTOMY SITE. [ NOTE: AN OPTIONAL TAP CAN BE USED FOLLOWING THIS STEP TO
CREATE SCREW THREADS IN AREAS OF DENSE BONE].BONE TAPPING NOT DONE IN SOFT
AND POOR QUALITY BONE IN POSTERIOR MAXILLA. BONE TAPPING AND IMPLANT
INSERTION ARE DONE AT A VERY SLOW SPEED 20-40rpm .ALL OTHER DRILLS IN THE SPEED
OF 800-1500rpm.
(G) IMPLANT INSERTION IN PREPARED OSTEOTOMY SITE WITH A HANDPIECE ROTATING AT
SLOW SPEEDS 25rpm.
(H) COVER SCREW IS PLACED AND SOFT TISSUES ARE CLOSED AND SUTURED.
 HEALING TIME
• IN GENERAL IMPLANTS ARE ALLOWED TO
HEAL FOR 2-6 MONTHS BEFORE THEY ARE
USED TO SUPPORT CROWNS, BRIDGES, OR
DENTURES. HOWEVER IF THE IMPLANTS IS
LOADED TOO SOON, IT IS POSSIBLE THAT THE
IMPLANT MAY MOVE WHICH RESULTS IN
FAILURE.THEREFORE IT IS IMPORTANT FOR
PATIENT TO FOLLOW POST OPERATIVE
INSTRUCTIONS CLOSELY TO MAXIMIZE
IMPLANT SUCCESS.
 ONE STAGE VS TWO STAGE SURGERY
• WHEN AN IMPLANT IS PLACED,IT CAN EITHER BE BURRIED UNDER THE
GUM DURING THE HEALING PERIOD. THIS IS A TWO-STAGE SURGERY
BECAUSE AFTER THE HEALING PERIOD A SECOND SURGERY IS NEEDED TO
EXPOSE THE BURRIED IMPLANT.
• IMPLANTS CAN ALSO BE PLACED IN A ONE-STAGE SURGERY WHERE IT IS
LEFT EXPOSED THROUGH THE GUM. IN THIS CASE, A SECOND STAGE
SURGERY IN NOT NEEDED.
• TWO-STAGE SURGERY IS SOMETIMES CHOSEN WHEN A BONE GRAFT IS
PLACED AT THE SAME TIME AS IMPLANT PLACEMENT.THIS WAY THE BONE
GRAFT IS LEFT UNDISTURBED UNDER THE GUM DURING HEALING.
• IN CAREFULLY SELECTED CASES,PATIENTS CAN BE IMPLANTED AND
RESTORED IN A SINGLE SURGERY ,IN A PROCEDURE LABELED “IMMEDIATE
LOADING”.IN SUCH CASES A PROVISIONAL PROSTHETIC TOOTH OR
CROWN IS SHAPED TO AVOID THE FORCE OF THE BITE TRANSFERRING TO
THE IMPLANT WHILE IT INTEGRATES WITH THE BONE.
 SURGICAL TIMING
THERE ARE DIFFERENT APPROACHES TO PLACE DENTAL
IMPLANTS AFTER TOOTH EXTRACTION. THE APPROACHES
ARE:
• IMMEDIATE POST-EXTRACTION IMPLANT PLACEMENT. P
• DELAYED IMMEDIATE POST-EXTACTION IMPLANT PLACEMENT [2WEEKS TO I
3 MONTHS AFTER EXTRACTION] [
• LATE IMPLANTATION [3 MONTHS OR MORE AFTER TOOTH EXTRACTION].
ACCORDING TO THE TIMING OF LOADING OF DENTAL
IMPLANTS,THE PROCEDURE OF LOADING COULD BE
CLASSIFIED INTO:
• IMMEDIATE LOADING PROCEDURE{ WITHIN 48 HOURS OF IMPLANT
INSERTION}.
• EARLY LOADING [ 1 WEEK TO 12 WEEKS ]
• DELAYED LOADING [ OVER 3 MONTHS]
 CRITERIA FOR IMMEDIATE LOADING

• SURGICAL FACTOR: TORQUE GREATER THAN 30 -35 N cm RESULTS IN

HIGHER SUCCESS RATES OF IMMEDIATE LOADING.COPIOUS IRRIGATION
TO MAINTAIN TEMP LESS THAN 47 DEGREE CELCIUS .

• HOST FACTOR: ORAL HYGIENE

• IMPLANT RELATED FACTORS: SURFACE STRUCTURE ROUGHENED

,IMPLANT LENGTH AND DIAMETER, SCREW DESIGN TYPE.

• OCCLUSAL FACTORS: MAX INTEROCCLUSAL COTACT WITHOUT LATERAL

CONTACT IS RECOMMENDED. PARAFUNTIONAL HABITS AND
COMPROMISED OCCLUSION SHOULD NOT RECEIVE IMMEDIATE LOADING
OPTION.
 IMPLANT FAILURE
• FAILURE OF DENTAL IMPLANT IS OFTEN DUE TO FAILURE OF IMPLANT TO
OSSEOINTEGRATE CORRECTLY WITH THE BONE,OR VICE-VERSA.
• A DENTAL IMPLANT IS CONSIDERED TO BE A FAILURE IF IT IS
MOBILE
SHOWS PERI-IMPLANT BONE LOSS OF GREATER THAN 1.0 mm IN THE FIRST YEAR
AND GREATER THAN 0.2 mm A YEAR AFTER.
• DENTAL IMPLANTS ARE NOT SUSCEPTIBLE TO DENTAL CARIES BUT THEY CAN DEVELOP
A CONDITION CALLED PERI-IMPLANTITIS. THIS IS AN INFLAMMATORY CONDITION OF
MUCOSA OR BONE AROUND THE IMPLANT WHICH MAY RESULT IN BONE LOSS AND
EVENTUAL LOSS OF IMPLANT. PERI-IMPLANTITIS IS MORE LIKELY TO OCCUR IN HEAVY
SMOKERS, PATIENT WITH DIABETES ETC. ( RISK OF FAILURE IS INCREASED IN SMOKERS.
FOR THIS REASON IMPLANTS ARE FREQUENTLY PLACED ONLY AFTER A PATIENT HAS
STOPPED SMOKING AS THE TREATMENT IS VERY EXPENSIVE).
• OVERHEATING DURING DRILLING ,THE NECROTIC AREA WILL PREVENT INGROWTHS OF
STEM CELLS, A SCAR FORMATION OR SEQUESTRUM FORMATION WILL RESULT. IMPLANT
PLACEMENT THUS IMPLIES PROFUSE COOLING WITH INTERMITTENT MODERATE-SPEED
DRILLINGWITH SHARP DRILLS.
• IN THE OPEN WOUND FRACTURE THE MICROBIAL CONTAMITATION JEOPARDIZES THE
NORMAL BONE REPAIR. SO IMPLANT ARE PLACED IN STRICT ASEPTIC TECHNIQUES.
 POST OPERATIVE CARE
• PATIENT CAN BE PREMEDICATED WITH ANIBIOTIC THERAPY ( AMOXICILLIN
500mg THREE TIMES A DAY [ tid] STARTING 1 HOUR BEFORE SURGERY AND
CONTINUING FOR 1 WEEK POSTOPERATIVELY IF THE SURGERY IS EXTENSIVE)

• CHLORHEXIDINE GLUCONATE ORAL RINSE CAN BE GIVEN TO FA CILITATE

PLAQUE CONTROL.
• ADEQUATE PAIN MEDICATION SHOULD BE PRESCRIBED[ IBUPROFEN,600 TO
800 mg tid]
• INSTRUCTED TO MAINTAINED SOFT DIET AFTER SURGERY.
• REFRAIN FROM TOBACCO AND ALCOHOL USE BEFORE AND SEVERAL WEEKS
AFTER SURGERY.
THANK
YOU