The Maya civilization has been shown to have used the earliest known examples of endosseous implants (implants

embedded into bone). While excavating Maya burial sites in Honduras in 1931, archaeologists found a fragment of mandible of Maya origin, dating from about 600 AD. This mandible, which is considered to be that of a woman in her twenties, had three tooth-shaped pieces of shell placed into the sockets of three missing lower incisor teeth.

HISTORY
1809- Maggiolo Introduced use of Gold in the shape of a tooth root. 1887- Harris Introduced use of teeth made of Porcelain in to which lead-coated platinum posts were fitted . 1900s- Lambotte fabricated implants of Al,Ag ,Brass, Red Copper , Magnesium,Gold & soft steel plated with gold & nickel.

 1909- The first root form design that differed significantly from the shape of tooth root was Greenfield Latticed cage design made of iridoplatinum. 1938- Strock surgical Co-Cr-Mo alloy was introduced to Oral Implantology. He replaced a single maxillary left incisor teeth with a root form one piece implant( lasted for more than 15 years)

 1940- Bothe & Coworkers A direct bone Implant interface to titanium was initially called bone fusing . 1946-Strock designed the first titanium two piece screw implant that was initially inserted without the Permucosal Post. 1952- Branemark began microscopic circulation of bonemarrow healing.

 1960s- Ten year Implant Integration was established in Dogs with no adverse reactions to hard or soft tissues.

Rationale for Dental Implant

The Goal of modern Dentistry is to restore the patient to normal contour, function, comfort, esthetics, speech & health . Implant Dentistry is unique in its ability to acheive the goal regardless of atrophy,disease or injury of the stomatognathic system.

 Increased need and use of implant related treatments result from combined effect of several factors including Ageing population living longer . Tooth loss related to age . Consequences of fixed prosthesis failure . Anatomic consequences of edentulism. Poor performance of removable prosthesis. Consequences of RPD

 Psychological aspects of tooth loss & needs & desires of ageing baby boomers. Predictable long term results of implant supported Prosthesis Advantages of Implant supported restorations Increased Public awareness.

Single Tooth Replacement-FPD

The most common choice to replace a posterior single tooth is a 3 unit FPD. & hence became the t/t of choice for last 6 Decades. Estimated mean life span of FPD (50%survival) reported at ten years. Caries is the most common cause of FPD Failure. 15% of FPD abutments require endodontics.


Failure of abutment teeth of FPD 8%-12% at ten years & 30% at 15years. 80% of teeth adjacent to missing teeth have no or minimal restoration.

Comparative Evaluation.

Single Tooth Implant

Rather than removing sound tooth structure and giving crown 2 or more teeth thus increasing the risk of decay & endodontic therapy a Dental Implant may replace a single tooth. Advantages High Success rates ( above 97% ) for ten years. Decreased risk of caries of adjacent teeth. Decreased risk of endodontic Problems on adjacent teeth.


Improved ability to clean the Proximal surfaces of the adjacent teeth. Improved Aesthetics of adjacent teeth. Improved maintanance of bone in edentulous site. Decreased cold or contact sensitivity of adjacent teeth Psychological advantage.


Decreased abutment tooth loss.

Anatomical Consequences of Edentulism


Loss of anterior ridge and nasal spine causing increased denture movement and sore spots during function. Increased risk of mandibular body fracture from advanced bone loss. Effect of bone loss on esthetic appearance of lower third of face. More active role of tongue in mastication.


Paresthesia from dehiscent mandibular neurovascular canal. Loss of basal bone. Thinning of mucosa with sensitivity to abrasion. Forward movement of prosthesis from anatomical inclination.

Soft Tissue Consequences of Edentulism Attached,keratinized gingiva is lost as bone is lost.

Unattached mucosa for denture support causes

increased soft spot. Thickness of tissue decreases with age and systemic disease causes more sore spots for dentures. Tongue increases in size , which decreases denture stability.


Tongue has more active role in mastication , which decreases denture Stability. Decreased Neuromuscular control of Jaw in the elderly.

Esthetic consequences of bone loss

Decreased Facial Height. Loss of labiomental angle. Deepening of vertical lines in lip and face. Chin rotates forward gives a Prognathic appearance. Decreased horizontal labial angle of lip-makes patient look unhappy. Loss of tone in muscles of Facial expression.


Thinning of Vermilion border of the lips from loss of muscle tone. Deepening of nasolabial groove. Increase in Columella-Philtrum angle. Increased length of Maxillary lip , so less teeth show at rest and smiling ages the smile. Ptosis of Buccinator muscle attachment leads to Jowls at side of face. Ptosis of Mentalis muscle attachment- leads to witchs chin

WitchS Chin

Jowls at side of face

Negative effects of removable Prosthesis.

Bite force is decreased from 200Psi-to 50 Psi 15-year denture wearers have reduced bite force to 6Psi. Masticatory effieciency is decreased. More drugs are necessary to treat GIT disorders. Life span may be decreased. Food selection is limited. Healthy food intake is decreased.


20% of edentulous patients dont wear both removable prosthesis all the time. (NIH Oral health of US adults national findings Publ No 87 1987) 7% of edentulous patients are not able to wear their dentures at all (NIH). 88% of denture wearers have difficulty with speech (Misch LS Misch CE DentureSatisfaction: a patients perspective, Int J Oral Implant 1991)


62.5% of mandibular denture wearers had awareness of movement (Misch) 50% of denture wearers avoided certain food (Misch) 17% of denture wearers masticated better without prosthesis (Misch) 16.5% of mandibular denture wearers never wear denture (Misch)

Problems with Removable Partial Denture.

Low survival rate- 60% at four years. 35% survival rate at 10 years. Repair of abutment teeth rate 60% at 5years & 80% at ten years. Increased mobility , plaque bleeding upon probing and caries of abutment teeth . 44% abutment teeth loss with in ten years. Accelerated bone loss in edentulous region if wearing RPD.


1.Average bite force in first molar area 150-250 PSI with electronic strain gauge studies and edentulous person with dentures 50 PSI ( Howell, 1948). 2. 32% less masticatory efficiency with natural teeth compared to complete dentures(Rissen et al J Prosth Dent 1978)

 4.Tissue borne dentures yield: Increased bone loss, increased caries on rest teeth, increased mobility of rest teeth, increased bleeding upon probing, greater plaque retention, non compliance of use, speech inhibition, taste inhibition.(Vermeulen A et al:Ten year evaluation of removable partial dentures:survival rates based on retreatment,not wearing and replacement, J Prosthet Dent 1996)

Psychological Effects of tooth loss

Range from minimal to Neuroticism. Romantic situations affected. Oral Invalids unable to wear dentures. 88% claim some difficulty with speech & 25% claim significant problems. More than $200 million each year spent on denture adhesive to decrease embarrassment. Dissatisfaction with appearance , low self esteem. Avoidance of social contact.

PROSTHETIC REPLACEMENT ANALOGIES

Advantages of Implant supported Prosthesis.

Maintain Bone. Restore and maintain occlusal vertical dimension. Maintain facial esthetics. Improve esthetics ( teeth positioned for appearance versus decreasing denture movement. Improve Phonetics.


Improve Occlusion. Improve/ regain oral proprioception occlusal awareness. Increase Prosthesis success. Improve masticatory Performance/ maintain muscles of mastication and facial expression . Reduce size of Prosthesis.


Improve stability and retention of removable prosthesis. Increase survival times of Prosthesis. No need to alter adjacent teeth. More permanent replacement. Improve Psychological health.

KEY TERMS:
ALLOPLASTIC Related to Implantation of an inert foreign body. ANKYLOSIS A condition of joint or tooth immobility resulting from oral pathology ,surgery, or direct contact with bone. ANODIZATION An oxidation process in which a film is produced on the surface of a metal by electrolytic treatment at the anode.

 BIOACCEPTANCE Ability to be tolerated in a biological environment in spite of adverse effects. BIOACTIVE Capable of promoting the formation of hydroxyapatite & bonding to bone. BIOCOMPATIBILITY Ability of a material to elicit an appropiate biological response in a given application in the body.

 BIOINTEGRATION Process in which bone or other living tissue becomes integrated with an implanted material with no intervening space . ENDOSTEAL IMPLANT A device that is placed in to the alveolar and / or basal bone of the mandible or maxilla , which transects only one cortical plate.

 EPITHELIAL IMPLANT A DEVICE PLACED WITH IN THE ORAL MUCOSA. IMPLANTATION Process of grafting or inserting a material such as an inert foreign body( ALLOPLAST) Or tissue with in the body. ION IMPLANTATION Process of altering the surface of a metal with desirable ionic species.

 OSSEOINTEGRATION Process in which living bony tissue forms to with in 100A of the implant surface without any intervening fibrous connective tissue. OSTEOINDUCTIVE Ability to promote bone formation through a mechanism that induces the differentiation of osteoblasts. PASSIVATION Process of transforming a chemically active surface of a metal to a less active surface.

 REPLANTATION Reinsertion of a tooth back in to its jaw socket soon after intentional extraction or accidental removal. SUBPERIOSTEAL IMPLANT A dental device that is placed beneath the periosteum and overlies cortical bone. TEXTURING: Process of increasing surface roughness of the area to which bone can bond.


Transosteal Implant A device that penetrates both cortical plates and the thickness of the alveolar bone.

IMPLANT MATERIALS

 Historically,titanium has been used extensively in aerospace, aeronautical and marine applications because of its high

weight, its ability to withstand high temperatures and its

strength and rigidity, its low density and corresponding low
resistance to corrosion.


Titanium's useful range of applications in biomedical

devices. Today, titanium and titanium alloys are used

for the fabrication of prosthetic joints, surgical splints,stents and fasteners, dental implants, dental crowns and partial denture frameworks.

Titanium Metal

 Titanium, in the form of the oxide rutile, is abundant in

the earth's crust. Titanium ore can be refined to metallic

In its metallic form at ambient temperature, titanium

titanium through the Kroll process. has a hexagonal, close-packed crystal lattice (ex phase),

which transforms into a body-centered cubic form (B

phase) at 883C (with a melting point of 1,680 C).

 This reactivity is responsible for many of titanium's favorable properties. The metal oxidizes almost

instantaneously in air to form a tenacious and stable

oxide layer approximately 10 nanometers thick. This oxide layer provides a highly biocompatible surface and a corrosion resistance similar to that of noble metals.


In addition, the oxide layer allows for bonding of fused porcelains, adhesive polymers or, in the case of endosseous implants, plasma-sprayed or surfacenucleated apatite coatings.

Generic Implant body terminology

There are currently more than 90 implant body designs offering combinations of design features Screws, Baskets, Plateaus,balls , Cylinders, diameters, lengths, Prosthetic connections & surface conditions. The most common root form design combines a separate implant body and Prosthodontic abutment.

Design & surgical Philosophy

To achieve clinical rigid fixation that corresponds to a microscopic direct bone to implant interface without intervening fibrous tissue occuring over significant portion of the implant body before the Prosthetic phase of the Procedure.


Three different surgical approaches have been used for 2 piece Implant System A) Two Stage ( Healing Submerged then uncovery surgery) B) One stage ( Implant with Permucosal healing no uncovery surgery) C) Immediate restoration ( Restoration Placed at the time of the surgical Placement.


Submerged approach in which implant is placed below or at the level of the bone, requiring second surgery to place the abutment (A) Non-submerged two-piece implants in which both the implant and abutment are placed during the first-stage surgery, eliminating the need for second surgery (b). Non-submerged one-piece implants in which implant and abutment are there as one piece with no micromovement between implant and abutment and no microgap. Moreover, there is no need of second surgery( c).


There are three primary types of root form body endosteal implant based on design Cylinder, Screw Or Combination. Cylinder (Press fit) root form implants depend on a coating or surface condition to Provide Microscopic retention to the bone. Surface is either coated with a rough material ( Hydroxyapatite ,Titanium Plasma Spray) or a macro retentive design ( Sintered Balls)

IMPLANT BODY REGIONS

Crest Module( Cervical Geometry).

A body.

An Apex.

 IMPLANT BODY- Designed for surgical ease or

Prosthetic loading to implant bone interface.

Round Implant permits round surgical drill. Smooth walled Cylinder implant- Implant to be Pressed or tapped in to position.(c/o ) single tooth implant application if adjacent to teeth with tall clinical crown)

 Solid screw Implant Body most commonly reported in literature. Solid screw body or implant of circular cross section without penetrating any vents or holes. Thread may be V shaped , Buttress, Reverse buttress or square.

THREAD PROFILING


Most Common Specifications Outer thread Diameter 3.75mm,

Thread Depth Thread Pitch-

0.38mm,
0.6mm

Thread Terminology


Body Length7-16mm.(5-56mm available)

Crest Module
Crest Module of an Implant body is that portion designed

to retain the Prosthetic component in a one Piece or two

piece implant system.

Represents the transition zone from the Implant body

design to the transosteal region of the implant at the crest of the ridge.

Crest Module

 Implant Body has design to transfer Stress Strain to the bone during occlusal loads e.g threads or large spheres

where as Crest Module is designed to reduce Bacterial Invasion.e.g (smoother to impair plaque retention if crestal bone loss occurs.) Its smoother dimension varies greatly from one system to another (0.5-5mm)


When the crest module is smooth , polished metal is often called a cervical collar. The Prosthetic connection to the crest module is received by Slip fit or friction fit with a butt or bevel joint.

Implant Surgery
A first stage cover screw is placed in to the top of

Implant to prevent Bone, Soft tissue & Debris from

invading the abutment connection area during healing . When supporting bone interface is developed a second stage Procedure is performed to expose the two stage Implant or to attach a transepithelial portion .

 This Transepithelial portion is called Permucosal Extension because it extends the Implant above the soft

tissue results in development of Permucosal seal.

Transepithelial portion or Permucosal extension been called a healing abutment since Stage 2nd uncovery surgery uses this device for initial soft tissue healing .

Prosthetic Attachments
The Abutment is the portion of the Implant that supports or retains a Prosthesis or Implant Superstructre . A Superstructure is defined as a metal framework that attaches to the Implant abutment and Provides either retention for a removable Prosthesis ( A cast bar retaining an overdenture with attachments ) or the framework for the fixed Prosthesis.

3 categories of Implant Abutments According to method by which the Prosthesis or

Superstructure is retained to the abutments-

1) An abutment for Screw retention uses a screw to retain the Prosthesis or superstructure. 2) An abutment for cement retention uses dental cement to retain the Prosthesis or Superstructure 3) An abutment for attachment uses an attachment device to retain a removable Prosthesis( O ring attachment)

 Above mentioned abutment types be classified as straight or angled abutments describing the axial relationship between the Implant body and the abutments.

Straight or angled abutment.

Prosthesis An impression is necessary to transfer the position and Fabrication design of the Implant or abutment to the mastercast for Prosthesis fabrication.
A transfer coping is used in traditional Prosthetics to position a die in an Impression . A transfer Coping is used to position an analog in an Impression and is defined by the Portion of the Implant it transfers to the master cast.

Basic Implant Restorative Techniques An Indirect transfer coping is screwed in to the

abutment or implant body and remains in place when a traditional closed tray Impression is set and removed from the mouth. Uses an Impression material requiring elastic Properties.

Direct Transfer coping

Consists of a hollow transfer component often square& a long central screw and secure it to the abutment or Implant body may be used as a Pick-up Impression coping. An Open tray impression tray is used to permit direct access to the long central screw securing the Indirect transfer coping. After Impression material is set the direct transfer coping screw is unthreaded to allow removal of the impression from the mouth.


Direct Transfer Copings take advantage of Impression materials having rigid Properties & eliminate the errors of permanent deformation since they remain with in Impression until the master model is poured.

Laboratory Fabrication
An Analog is defined as that is analogous or similar to something else. An Implant analog is used in the fabrication of the master cast to replicate the retentive portion of the Implant body or abutment( Implant Body Analogue, Implant Abutment analogue.)


After the master Impression is obtained the corresponding analog is attached to the transfer coping & the assembly is poured in stone to fabricate the master cast.

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Diognostic Imaging & Techniques

IMAGING OBJECTIVES
The decision of when to image along with which imaging modality to use depends on the three phases-

Presurgical Imaging ( Phase 1)

Preprosthetic implant imaging (Phase 1): The objectives of this phase are to determine the quantity, quality, and angulation of bone; the relationship of critical structures to the prospective implant sites; and the presence or absence of disease at the proposed surgery sites.

 Surgical and Interventional implant imaging (Phase 2): The objectives of this phase are to evaluate the surgery sites during and immediately after surgery, assist in the optimal position and orientation of dental implants, evaluate the healing and integration phase of implant surgery, and ensure abutment position and prosthesis fabrication are correct.


Post prosthetic implant imaging (Phase 3): It commences just after the prosthesis placement and continues as long as implant remains in the jaw. The objectives of this phase are to evaluate the longterm maintenance of implant rigid fixation and function, including the crestal bone levels around each implant, and to evaluate the implant complex.

Types of Imaging Modalities:

Periapical Radiography. Panoramic Radiography. Occlusal Radiography. Cephalometric Radiography. Tomographic Radiography. Computed Tomography. Magnetic Resonance Imaging. Interactive Computed Tomography.

Basic radiographic principles

1. Adequate number and type of images to provide the needed anatomic information. 2. The type of imaging technique selected should be able to provide the required information with adequate precision and dimensional accuracy. 3. There must be a way of relating the images to patient's anatomy. For edentulous regions of jaw, this generally means the use of a stent with radiopaque markers during imaging. 4. All images should be of adequate density and contrast with minimal distortion and should be free from artifacts. 5. Imaging information should be balanced with the radiation dose and cost to the patient. The ALARA (as low as reasonably achievable) principle should govern the selection of suitable technique .

Ideal imaging modality characteristics According to Pharoah MJ 1993

1. Cross-sectional views for the visualization of the

spatial relationship of internal structures, such as the inferior alveolar canal, and as a means of obtaining accurate dimensions in both the vertical and the horizontal planes. 2. Minimal image distortion to permit accurate measurements. 3. Depiction of the density of the cancellous bone and thickness of the cortical plates of bone. This is of value if initial stabilization of the implant is required.


4. Spatial relationship of the cross-sectional views of the mandible and maxillae to one another. 5. A simple means of identifying the exact location of each cross-sectional image to the implant site that can be provided at the time of surgical placement. 6. Ready availability and reasonable cost. 7. Patient radiation dose should be small as possible .


Bone classification related to implant dentistry

Lekholm and zarb alveolar bone grading scale

According to this system alveolar bone has been divided into 4 classes: 1. Almost the entire jawbone is composed of homogenous compact bone. 2. Thick layer of compact bone surrounds a core of dense trabecular bone. 3. A thin layer of compact bone surrounds a core of dense trabecular bone of favourable strength. 4. A thin layer of compact bone surrounds a core of low density trabecular bone. The quality of the implant site in terms of relative proportion and density of cortical and medullary bone had frequently been assessed using a grading scheme.

Lindh et al method of classification of alveolar bone

It is a recent method of classification based on periapical radiographs that grades the medullary bone as A) Dense B) Sparse and C) Alternating dense and sparse trabeculation.

.
Classification by Lenkholm and Zarb: (I) the jaw consists almost exclusively of homogeneous solid bone structure; (II) a wide compacta surrounds a densely spongiosa; (III) a small compacta surrounds a densely spongiosa with a good resistance; (IV) a small corticalis surrounds porous

Misch Bone Density Classification

Dl - Dense cortical bone, D2 - Thick dense to porous cortical bone on crest and coarse trabecular bone within, D3 - Thin porous cortical bone on crest and fine trabecular bone within, D4 - Fine trabecular bone and D5 - Immature, non-mineralized bone.

Misch Bone Density Classification

 Bone density may be more precisely determined by tomographic radiographs, especially computerized tomograms. Computerized tomography (CT) produces axial images of the patient's anatomy, perpendicular to the axis of the body. The bone density may be different near the crest compared with the apical region where the implant placement is planned. The most critical region of bone density is the crestal 7 to 10 mm of bone. Therefore when the bone density varies from the most crestal to apical region around the implant, the crestal 7 to 10 mm determines the treatment plan protocol .

Radiographic bone density

 Intraoral periapical radiographs, are made using paralleling technique . Periapical radiography used to rule out the presence of pathosis, location of anatomic structures in relation to implant site . It also determines vertical height, architecture and bone quality [density, amount of cortical bone and amount of trabecular bone]

Imaging modalities

Digital Radiography:
Direct digital intraoral imaging is an emerging and alternative technique to film radiography. It allows rapid acquisition of intraoral images and their enhancement, their storage, retrieval, and transmission to remote sites. The future utility of digital imaging may rest with the operators ability to manipulate image density and contrast and to measure bone density at specific sites .

Intraoral imaging using electronic or CCD imaging techniques: With charge coupled devices (CCDs) presurgical implant

assessment of single sites becomes precise. CCDs allow accurate measurement of implant sites preoperatively and provide more information about osseointegration postoperatively than with film. The use of wire grids helps in site selection and bone height determination. Multiple images of a site allow two and three dimensional reconstruction of the proposed site and allow viewing the information on a video monitor prior to placement .

Occlusal Radiographs
Occlusal radiographs are used for the edentulous mandible/maxilla to obtain information regarding bucco-lingual width and contour . Applications: Individual implant sites and mapping for multidirectional tomography.

Cephalometric radiography Cephalometric radiographs with lateral, posteroanterior

and oblique views of the jaws will provide pertinent information like angulation, thickness and vertical bone height in the midline, inter-jaw skeletal relationships and the soft tissue profile . Together with regional periapical radiographs, quantitative spatial information is available to demonstrate the geometry of implant site and the spatial relationship between implant site and critical structures such as the floor of nasal cavity, the anterior recess of maxillary sinus and the nasal palatine canal .

Panoramic radiography
Panoramic radiographs are used for the longitudinal assessment of the success of the implant. Panoramic images provide a broader visualization of the jaws and adjoining anatomic structures. These are widely available and can be used as screening radiograph. They are also used to assess the crestal alveolar bone and cortical boundaries of the mandibular canal, maxillary sinus and nasal fossa .


Zonography: Recently, a modification of the panoramic x-ray machine has been developed that has the capability of making a cross-sectional image of the jaws. These devices employ limited angle linear tomography (zonography) and a means for positioning the patient. This technique enables the appreciation of spatial relationship between the critical structures and implant site and quantification of geometry of implant site. It has limited usefulness, especially in the anterior regions. The tomographic layers are relatively thick and have adjacent structures that are blurred and superimposed on the image, limiting the usefulness of this technique for individual sites, especially in the anterior regions where the geometry of alveolous changes relatively rapidly. This technique is not useful for determining the differences in most bone densities or identifying disease at implant site .

Cross Sectional Imaging

Cross Sectional Imaging Cross sectional imaging include - Conventional tomography. - Computed tomography (CT).
- Magnetic resonance imaging (MRI).

Conventional tomography:

Conventional film- based tomography is designed to obtain clear images of structures lying within a plane of interest . It used for accurate assessment of alveolar bone height, width and inclination. It can assess both the quality and quantity of the bone. It gives information regarding the spatial relationship of vital structures .

Computed tomography (CT):

CT was first applied successfully in implantology in the 1980s . In CT implant imaging, multiple thin axial slices are obtained through jaws and then the data are reformatted with special software packages to produce cross-sectional and panoramic views. Computer software programs are available to analyze the reformatted images and aid in planning implant placement with electronically simulated fixtures, measure the distance from the alveolar crest to vital structures . Computer assisted tomography has become popular in implant and temporomandibular joint imaging with the advent of precise positioning techniques controlled by computer work stations.


The complex motion tomographic machines incorporates most of the complex motions of tomography like circular, trispiral, elliptical, hypocycloidal .

Principle
The tomogram is obtained by moving the source of x-rays in one direction and the receptor (film or digital sensor) in the opposite direction around the object in the focal plane. This sharpens the object in the rotation centre as it is always in the same place on the sensor, and blurs/hides the structures that are not in the focal plane as they are projected in different parts of the sensor during the movement. Objects that are situated before the slice are blurred and smaller, objects behind the slice are blurred and larger. The thickness of the slice has an influence on the image: a thin slice provides more details by better removing the objects outside the focal plane, but reduces the contrast. The thickness of the slice is determined by the angle of the slice; a wide angle (long trajectory) will give a finer slice. A zonography is a tomography with a slice thickness superior to 5mm.

Figure 2: Conventional tomogram showing clear plastic overlay used to visualize and determine desired length of implant placement (11).

Figure 3: Axial CT view of the mandible showing the potential crosssectional slices that can be reformatted by Dentascan (18).

Cone Beam Computed Tomography

Cone beam CT is a relatively newer modality, specifically designed for maxillofacial imaging introduced in the late 1990s. It is characterized by true volumetric data acquisition obtained simultaneously during one rotation of the x-ray source. It produces a 3-D image volume that can be reformatted using software for customized visualization of the anatomy. It gives all the information of CT at 1/8th the radiation dose and at a lower cost (17).

 TACT is a new and promising method for dentoalveolar imaging based on optical aperture theory. This technique uses information collected by passing a radiograph beam through an object from several different angles. A prototype developed for dental applications has a cluster of small radiograph tubes that can be fired in close sequence. The relationship of the source and the object can be used to determine projection geometry after the exposure is complete. TACT can map the incrementally collected data into a single 3- dimensional matrix. It can isolate the images of desired structures limited to certain depths. It has the ability to accommodate patients motion between exposures. It has considerable flexibility to adjust contrast and resolution .

Tuned Aperture Computed Tomography (TACT)

Accurate distance determinations between horizontally aligned structures such as the mandibular canal and a vertically aligned structure such as a Dental Implant

Using TACT

Magnetic resonance imaging (MRI):

Magnetic resonance imaging (MRI) is based on the phenomenon of nuclear magnetic resonance (NMRI). First described in 1946, its application in implantology is however of recent origin . MRI with a 0.2 Tesla low field scanner, has shown definite potential as a future replacement for CT imaging with the obvious advantages that it delivers no ionizing radiation . MRI is used in implant imaging as a secondary imaging technique when primary imaging techniques fail. MRI visualizes the fat in trabecular bone and differentiates the inferior alveolar canal and neurovascular bundle from the adjacent trabecular bone .


Oriented MRI imaging of the posterior mandible is dimensionally quantitative and enables spatial differentiation between critical structures and the proposed implant site. MRI is not useful in characterizing bone mineralization or a high-yield technique for identifying bone or dental disease .

Figure 4: A transaxial image showing the marker indicating the potential implant site (arrow). The lines show the planned position of a set of images at right-angles to the maxilla at the site (20)


Advantages: MRI can sharply delineate soft
and hard tissues, differentiate between cortical and cancellous bones, zero radiation dose, flexibility of plane acquisition, gives good soft tissue details and less artifacts.

Disadvantages: Expensive, no special

software is available for specific use in implantology, an expert radiologist is required to interpret and its application in implantology is still in its experimental phase

 Periapical radiographs may be supplemental when high detailed images are indicated. To assess the suitability of an implant site i.e. to assess the mesial/distal view, a panoramic radiograph is appropriate because it provides the view of both jaws. Imaging information from panoramic, cephalometric and intra-oral films alone is inadequate to evaluate the bony architecture of any implant site completely.

Diagnostic imaging for preoperative planning


The AAOMR recommends that evaluation of any potential implant site include cross sectional imaging orthogonal to the site of interest. This information is best acquired with tomography, either conventional or CT. Conventional film tomographic views are most useful when complex motions are used such as spiral or hypocycloidal patterns, instead of linear movement. CT is most appropriate for patients who are being considered for many implants [8-10 or more]

Surgical and interventional imaging

Surgical and interventional imaging involves imaging the patient during and immediately after surgery and during the placement of the prosthesis. The purpose of surgical imaging is to evaluate the depth of implant placement, the position and orientationof implants/osteotomies, and to evaluate donor or graft sites. Because most implant surgeries are performed in the doctor's office rather than a hospital, the modalities are usually limited to periapical and panoramic radiography

Digital periapical radiography Digital periapical image receptors enable virtually instantaneous image acquisition, produce image quality and enable the surgical similar to that of dental film,
procedure to proceed without undue delay.


Image enhancement and the digital measuring techniques, can help the surgeon in establishing the optimum depth and orientation of the implants . The image can be manipulated to change the density and contrast and to measure the bone density at specific sites.

Panoramic Radiography
For extensive implant procedures that may involve the entire jaw, both jaws, large donor graft sites, or sinus graft augmentation, panoramic radiography will provide a more global view of the patient's anatomy. Patient must generally leave the surgical site and stand or sit still for the panoramic procedure, less resolution and shows magnification and distortion .

Postsurgical assessment
The purpose of post-prosthetic implant imaging is to evaluate the status and prognosis of the dental implant. The bone adjacent to the dental implant should be evaluated for successful integration, fibrous tissue interfaces, inflammation, or infection, loss of crestal bone adjacent to the dental implant, excessive functional loading, or para functional loading. Loss of cylindrical bone volume adjacent to the implant surface may indicate excessive axial or shear loading, bone damage during implant placement, integration failure with an epithelial bone implant interface, inflammation, and/or infection .

 Loss of cylindrical bone volume adjacent to the implant surface may indicate excessive axial or shear loading, bone damage during implant placement, integration failure with an epithelial bone implant interface,inflammation, and/or infection .

Figure 5: Periapical radiograph showing moderate bone loss (saucerization type) cervical region (11).

 Marginal bone loss of approximately 1.2 mm in the first year and 0.1mm is subsequent years is generally considered acceptable. Conventional intraoral and panoramic radiography are most widely used for post surgical assessment and in most cases, are adequate for this task. The short- and long-term evaluation of crestal bone loss around implants is best evaluated with Bite-wing radiographs. In these images, the superior one third of the implant is the region of interest . Cross-sectional imaging is usually not required for routine post-surgical evaluation of implants. However, it may be of benefit in certain cases to evaluate potential complications


The short- and long-term evaluation of crestal bone loss around implants is best evaluated with Bitewing radiographs. In these images, the superior one third of the implant is the region of interest . Crosssectional imaging is usually not required for routine post-surgical evaluation of implants. However, it may be of benefit in certain cases to evaluate potential complications

Processed stent with metal cylinders marking the implant sites


The value of imaging may be enhanced with the use of an imaging stent. The intended implant sites are identified by markers made of radiopaque spheres or rods (metal, composite resin, and gutta-percha) retained within an acrylic stent which the patient wears during imaging procedure . Diagnostic dentures coated with barium paste may be used during imaging. Only nonmetallic radiopaque markers are (gutta-percha, composite resin) used in CT imaging because metal markers produce image artifacts

A 3/32-inch twist drill was used to create a pilot hole through the denture tooth on the cast.

A guide pin is placed into the pilot hole on the cast to verify position and angulation.

A stainless-steel sleeve is placed on the guide pin with the retentive bracket toward the lingual.

stent fabricated with Triad gel is carried over the incisal edge to create stability of the stent to the adjacent teeth.

The surgical stent is shown intraorally.

Summary and conclusions

Many radiographic projections are available for implant imaging. Intraoral, panoramic and cephalometric radiography may be used best during initial phase of patient evaluation. Once the decision for implant placement has been made, the proposed site must be further evaluated using conventional tomography or CT. Film tomography is the most cost effective technique for evaluating single sites or several sites within the same quadrant multiple sites several quadrants in dentate patients or multiple sites in edentulous patents may be more effectively studied by CT. MRI is not commonly used for implant imaging because bony detail cannot be readily appreciated.

A 2-mm osteotomy drill is being used through the surgical stent intraorally.

placed using the surgical stent demonstrates final positioningrelative to the stents sleeve.

A radiograph showing an open Guide Right sleeve for placement of a lower first molar.

Osteotomy drill being used in an open sleeve Guide Right surgical stent.

Final implant placement achieved using the open sleeve Guide Right surgical stent.


. Stents facilitate the application of bone measurements from the radiograph to the clinical scenario. Stents also may be designed to evaluate the path of insertion and axial inclination of the anticipated implant and the emergence profile of the implant. Most imaging stents can be converted to surgical guides for use in the surgical phase of implant treatment to orient the insertion angle of the guide bur and the angle of the implant. For optimal visualization the width of the markers should be less than the thickness of conventional tomographic image layer .

Dosimetry

Definitions

Radiographic template: Acrylic resin guide used by the surgeon to direct the placement of an implant into its proper position. It uses information from 2D panoramic radiographs and 3D CT or digital volume tomography (DVT) scans to achieve optimal implant body placement within the available bone and to preserve vital structures.


Image guidance: General technique of using preoperative diagnostic imaging with computer-based planning tools to facilitate surgical and restorative plans and procedures.


Imaging guide: Scan to determine bone volume, inclination, and shape of the alveolar process, and bone height and width used at a surgical site.


Surgical navigation: Computer-aided, intraoperative navigation of surgical instruments at the operation site using real-time matching to the patient's anatomy. During surgical navigation, deviations from the preoperative plan can be immediately observed on the monitor.


Computer-aided navigation: Intra-operative navigation computer systems provide the surgeon with current positions of the instruments and the operation site on a 3D reconstructed image of the patient that is displayed on a monitor inthe operating room. System aims to transfer pre-operative planning on radiographs or CT scans of the patient in real time and independent of the position of the patients head.


Surgical template (surgical guide): Laboratoryfabricated guide based on ideal prosthetic

positioning of implants used during surgery.


Stereolithographic guide: Surgical guides that assist placement of implants in vivo in the same location and direction as those in a planned simulation. Stereolithography (3D layering and 3D printing) is a technique that is used to create solid plastic 3D objects from CAD drawings by selectively solidifying an ultraviolet-sensitive liquid resin (photopolymer) using a laser beam.


Immediate loading: Application of a functional or non-functional load to an implant at the time of or shortly after surgical placement, generally loaded within 48 h of implant placement.

Use of Stereolithographic
Templates for Surgical and Prosthodontic Implant Planning and Placement.


J Prosthodont 2006;15:117-122.

Clinical and Radiographic Findings

Clinical examination revealed defective amalgam

restorations, extruded teeth in the maxillary arch,

and bilateral, long-span, fixed partial dentures (FPDs) in the posterior part of the mandible. The FPDs were fabricated without correcting the unacceptable plane of occlusion resulting

from the extruded maxillary teeth.


There were working and nonworking side interferences in the molar region resulting in a restricted range of mandibular movement. The prostheses had open margins with resultant secondary caries in the abutment teeth.


The porcelain had fractured off in several places resulting in the exposure of metal substructure and unacceptable occlusion. Periodontal charting revealed probing depths between 6 and 9 mm, and significant bleeding was observed on probing.


Radiographic examination revealed periapical lesions around all the abutment teeth with significant

bone loss.

 The

diagnostic

casts

were

articulated

on

semiadjustable articulator using

facebow transfer

and a centric relation interocclusal record.

A comprehensive treatment plan was presented to the patient based on clinical and radiographic findings, articulated diagnostic casts, diagnostic waxup, and, to some extent, the patients desires.

 After consultation with the endodontist and the periodontist, it was determined that the mandibular posterior teeth had a poor prognosis. The existing fixed partial dentures were removed and the teeth were extracted to eliminate the periodontal pathology.

Diagnostic Wax-Up/Radiographic Template

A diagnostic wax-up was done, and a Broaderick occlusal plane analyzer was used to develop an ideal plane of occlusion. The diagnostic waxup

was duplicated in the form of a radiographic

template using resin.


Gutta-percha markers were placed in the mesio-distal centers of the buccal aspect of the teeth in the resin template. (It might have been better to have used barium sulphate denture teeth, for the radiographic template for more precise planning).

 The barium teeth are a more accurate representation of the intended restoration as they appear on the reformatted CT data. This would prevent the possibility of deviating

from the confines of the intended restoration while moving the simulated implants or using angulation correcting abutments.


Denture teeth of molds identical to the barium teeth may then be used for fabricating a fixed or removable interim prosthesis using a vinylsiloxane index made from the radiographic template.

Scanning Procedure
The patient was sent for a spiral CT scan with 1 mm slice intervals and a 0 gantry tilt. The raw data were sent electronically for reformatting into a virtual 3D model along with parasagittal views of the bone.

12 shows 0 degree Gantry tilt

3D Computer Simulation
The implant simulation was carried out using Surgicase software with the 3D model and parasagittal views The surgeon finalized the length and diameter of each implant along with their optimal spatial positioning within the bone. On the right side,the two distal implants were kept shorter due to proximity to the inferior dental alveolar canal.


The abutments were also selected at this stage based on the angulations of the implant as they related to the 3D representations of the guttapercha markers used in the radiographic template. On the left side, use of angulated abutments would not be necessary,as the long axes of the four implants appeared to be emerging from the center of the occlusal surface of the intended definitive restoration.


The finalized 3D simulation was electronically sent to lab. The stereolithographic models and templates (Surgiguides) were received after 2 weeks (Fig 6).

 Prior to surgery, a second set of templates were

used to drill holes in the stereolithographic model

to familiarize the surgeon with the system. The mandibular nerve was selectively colored red and the remaining osseous structure of the mandible was made transparent in the stereolithographic model.


Following the trial drilling on the model, it was reassuring to see that the drill sites were well away from the nerve and closely resembled the 3D model of the computer simulation. This model could be articulated with the cast of the opposing dentition and used to fabricate an interim definitive prosthesis.

Surgical Procedure Since it was the first time the system was being
used by this team, implant placement was carried out separately for the right and left sides. A fullthickness mucoperiosteal flap was reflected and the first template corresponding to the 2-mm twist drill was seated. Care was taken to prevent the free ends of the flap from interfering with the seating of the template

 Osteotomies with the 2-mm drill were completed and then enlarged using the second template corresponding to the 3-mm twist drill.

Implants were placed and conventional procedures were followed for the two-stage procedure. At this point, dimensions of all implants used during surgery were compared with those planned preoperatively; they were identical for all eight implants.


Implants were allowed to integrate for a period of 4 months during which time the patient was wearing a removable partial interim prosthesis.

Prosthodontic Procedure
Following second-stage surgery, an implant-level impression was made using polyether impression material (Impregum, 3M, St. Paul, MN) along with a new centric relation record to articulate the master casts.


The previously selected abutments were oriented appropriately on the cast using a clear vacuumformed template of the initial wax-up as a guide. The metal framework was then fabricated along with an interim fixed prosthesis at the abutment level. GC pattern resin (GC Corporation, Tokyo, Japan) was used to connect the abutments together in the form of an abutment transfer assembly to help transfer them intraorally.


The abutments were transferred to the implants and hand tightened. The metal framework was then tried in and radiographs were made to verify the seating of the abutments and framework.

 The framework was removed, abutment screws torqued, and the interim prosthesis secured in place over the abutments. The prostheses were tried in the patients mouth and functionally equilibrated.


. This was followed by the insertion of the definitive prosthesis. All the abutments used were identical to those planned and the resulting screwretained definitive prosthesis displayed screw access holes oriented in the center of the occlusal surfaces of the teeth (Fig 8). A posttreatment panoramic radiograph was made (Fig 9).


In addition, the screw access holes for all eight implants placed were predictably oriented near the center of the occlusal surface of the definitive prosthesis. At the 18-month postinsertion follow-up, probing depths were 3 to 4 mm and horizontal bitewing radiographs revealed stable bone levels corresponding to the first thread of all the implants.


That near ideal surgical and prosthodontic implant placement can predictably be achieved using stereolithographic templates (Figs 10 and 11). The mucosally supported templates could make the procedure less invasive and significantly reduce the time required for comprehensive oral rehabilitation with dental implants.

CONCLUSION
The imaging modalities that exist today can enhance the success and satisfaction with implant placement. Selection of projection should be made with consideration to the type and number of implants, location and surrounding anatomy. As in the case of all imaging, appropriate selection criteria must be applied individually to each patient.

THANK YOU!

STRESS TREATMENT THEOREM FOR IMPLANT DENTISTRY

The most common Implant related complications are biomechanical problems that occur after the Implant is loaded . The most common implant related complications are biomechanical problems occurs within 18 months after Implant is loaded .

Chapter FOUR STRESS TREATMENT THEOREM FOR IMPLANT DENTISTRY

Most Common Implant related Complications. The most common Implant related complications are
Biomechanical problems that occur after the Implant is loaded ( with in 18 months of initial Implant loading).

These early Implant loading failure occur mostly in Softest bone type (16% failure) or the shortest Implant length (17% failure).

 Biological

Biomechanical Implant Failure Failure

Stress Treatment Theorem: Biological vs Biomechanical

Early Loading
Micromovement. Cellular Engineering. Bone Mechanics

Surgical Failure. Biomechanics. Healing. Crestal Bone loss Periosteal Reflection. Osteotomy. Autoimmune. Biological Microgap. Prosthetic Complications Mechanics Screw loosening. Component Fracture. Fracture Implant Body Fracture. Fracture.

Attachment Wear Attachment Denture Tooth