PARTS OF A DENTAL IMPLANT INCLUDE: 1- CROWN 2- ABUTMENT 3- IMPLANT BODY 4- IMPRESSION COPING 5- ANALOGUE OR IMPLANT REPLICA 6- RETENTIVE ANCHORS

7- BAR RETAINER

THE PARTS OF A DENTAL IMPLANT ARE AS FOLLOWS:

1. CROWN Definition: The part of a tooth projecting from the gum.

Fig : Crowns Crowns are the top part of a restoration and are the part that we see in the mouth. They replicate the original teeth to provide a biting surface and aesthetic appearance. (Fig.18). They are hand made by the technician. The supporting substructure for the crown may be hand-made or machined (onsite or offsite). Material Used: Porcelains (metal supported or metal free) or metal (normally gold)

2. ABUTMENTDefinition: The lateral supporting structure of a bridge, arch, etc. The point of junction between such a support and the thing supported.(Fig.19)

Fig.19: Abutment An abutment provides support for the crown (or several crowns i.e. a bridge). It is also the interface between the crown and the implant. Rotation (twist) is controlled by lugs shaped on the abutments stem. These lugs restrict the abutments rotational placement by setting incremental steps. Materials Used: Titanium. 3. IMPLANT BODY Definition: An insert (tissue, a substance, a device, etc.) into the body.

Fig.: Implant Body Implant body may be further divided into (Fig 20) 1. Crest module 2. Implant body 3. Implant apex

An implant body provides the anchor or foundation for a restoration. It is screwed into the bone of the jaw providing a fixed platform on which an abutment can be screwed. Bone tissue can grow around the implant regenerating and strengthening the jaw reducing the bone loss which occurs when natural teeth are lost Materials Used: Titanium. 4. IMPRESSION COPING

Fig.: Impression Coping Impression copings are used by the dentist to replicate the position of the implant in the patients mouth. The dentist screws the impression coping to the real implant and then, using a specific impression technique, takes an impression of the dentition. (Fig 21) The impression technique can be open or closed: Open tray technique allows the dentist to remove the impression complete with impression coping(s) from the patients mouth by allowing external access to the copings retaining screw(s) i.e. the impression coping(s) remain fixed in the impression material. The dentist is then required to add the analogue(s) prior to dispatching to the lab. Closed tray technique requires that the dentist first removes the impression the patients mouth then unscrews the impression coping(s) to remove them from the implant. The impression coping(s) are then placed back into position by the dentist in the impression material and the analogues are added prior to despatch. Materials Used: Titanium, plastic, and anodized aluminium

5. ANALOGUE OR IMPLANT REPLICA

Fig .: Analogue

Analogues are used by laboratory technicians to replicate implants and their position in a patients mouth. A model of the patients dentition is cast using an impression. The analogue, screwed onto the impression coping, is set into the plaster model during casting. (Fig. 22) They provide an exact fixed reference platform (a replica of the position of the implant) from which the technician can place and shape the abutment and build the crown or bridge. Materials Used: Stainless steel (sometimes brass)

6. RETENTIVE ANCHORS

Fig .23: Retentive anchors Retentive anchors come in various types of design: Ball Abutment (with retaining clip), Magnetic Abutment (with retaining magnet) and Tower Abutment (which comes with a retaining clip). All come in two main parts: The shaped abutment part and the female which clips over it known as a Matrix.(Fig. 23)

Once the anchor abutments are screwed into the implants, they provide support for a full or a partial denture (which are clipped on). This provides a very stable platform and prevents unwanted movement of the prosthesis. Materials Used: Titanium and gold (with plastic matrices or magnetic material) 7. BAR RETAINERS

Fig .24: Bar retainers Constructed by laboratory technicians, bar retainers mount directly onto implants . A clip mechanism then secures a denture to the screw retained bar.(Fig. 24) There are two well known types, Dolder and Hader. These bars provide a strong support option for retaining dentures. They may be mounted on several different manufacturers implant systems. Materials Used: Titanium or gold (clips are plastic or brass) Requisites of an ideal implant restorative material It should be stable in the oral environment and should not undergo corrosion. It should fit passively over the implant abutment. It should be esthetic. It should not induce undue stresses in the implant or the bone. It should be biocompatible and should not induce any allergenic reaction. It should be easy to fabricate and handle.

 It should be easy to maintain. It should be cost-effective. The physical, mechanical, chemical and electrical properties of the basic material components must always be fully evaluated for any biomaterial application, as these properties provide key inputs into the biomechanical and biologic analysis of function. The materials used for dental implants can be classified according to their biological nature as follows: Biotolerant: Biotolerant materials are those that are not necessarily rejected when implanted into the living tissue, but are surrounded by a fibrous layer in the form of capsule. Bioinert: These allow close apposition of bone on their surface, leading to contact osteogenesis. Bioactive:These materials also allow the formation of new bone onto their surface, but ion exchange with host tissue leads to the formation of a chemical bond along the interface (bonding osteogenesis)

Biodynamic Activity

METALS

CERAMICS

POLYMERS AND COMPOSITES

Biotolerant

Gold Co-Cr alloys Stainless Steel Zirconium Niobium

Polyethylene Polyamide Polymethylmethacrylate Polytetrafluoroethylene Polyurethane

Tantalum

Bioinert

Commercially Pure Ti Ti alloy(Ti-6AI4V)

Aluminium Oxide Zirconium Oxide

Bioactive

Hydroxyapatite Tricalcium phosphate Fluroapatite Bioglass Carbon-silicon

Flowchart (3): classification of materials used for dental implants

1.METALS
The metals currently used are: a) Stainless steel It has high strength and ductility. The surface is passivated to increase biocorrosion resistance It is used in wrought and heat treated condition.

Precautions: It is contraindicated in patients sensitive to nickel. As it is susceptible to crevice and pitting corrosion, so care has to be taken to preserve passivated surface. It has galvanic potential, so avoid contact with dissimilar metal e.g. Base metal or noble metal bridge. b) Cobalt Chromium-Molybdenum Alloy It has high modulus (stiffness), low ductility, outstanding resistance to corrosion, excellent biocompatibility. Its commonly used for fabrication of custom design (e.g. frames) Precautions: A proper fabrication techniques should be used as composition is critical. It has poor ductility, so bending should be avoided. c) Titanium and Titanium Aluminium / Vanadium alloy Pure Titanium (Commercially pure titanium CpTi) has become material of choice because of its predictable behaviour with the oral tissues and environment. It has food corrosion resistance due to passivating effect. Oxide layer forms on cut surface within a millisecond, thus it is self healing. It has a low density i.e 4-5 g/cm2 , high strength to weight ratio, low stiffness as compared to stainless, yet 5 to 10 times greater than living bone. Precautions: Proper design should be used to distribute stresses properly. It releases titanium into blood and saliva, however side effects have not been seen yet. Metal with surface coatings This includes a titanium implant that is coated with a thin layer of a calcium phosphate ceramic. It can also be plasma sprayed. Advantages: Subperiosteal

The tricalcium phosphate or hydroxyapatite is rich in calcium and phosphorous. This produces a bioactive surface which promotes bone growth and forms a direct bone between the implant and the bone. d)Titanium and Ti-6al-4v This reactive group of metals and alloys form tenacious oxides in air or oxygenated solutions. This passivated surface minimizes the bio-corrosion phenomenon. In situations where the

implant would be placed within a closely fitting receptor site in bone, areas scratched or abraded during placement would re-passivate in vivo. The strength values for wrought soft and ductile metallurgic condition are approximately 1.5 times greater than the strength of compact bone. In most designs where the bulk dimensions and shapes are simple strength of this magnitude is adequate. Titanium shows relatively low modulus of elasticity and tensile strength when compared with most other alloys. Yet its modulus of elasticity is 5 times greater than that of the compact bone, and this property places emphasis on the importance of design in the proper distribution of mechanical stress transfer. Precautions: Sharp corners or thin sections must be avoided for regions loaded under tension or shear conditions e) Iron Chromium Nickel Based Alloys This alloy as with Ti systems is used most often in wrought and heat treated metallurgic conditions, which results in a high strength and high ductility alloy. The ramus blade, ramus frame, stabilizer fins and some mucosal insert systems have been made from the iron based alloy.

Precautions: Because this alloy contains nickel as major elements, use in patients allergic or hypersensitive to nickel should be avoided. Iron based alloys have galvanic potentials and corrosion characteristics that could result in concerns about galvanic coupling and bio-corrosion if interconnected with Titanium, Cobalt, Zirconium or Carbon implant biomaterials. f) Cobalt and Iron Alloys The alloys of Cobalt & Iron exhibit oxides of chromium under normal implant surface finishing conditions after acid or electro-chemical passivation. These chromium oxides as with Titanium alloys result in significant reduction in chemical activity & environmental iron transfer. In the absence of surface damage, the chromium oxide on stainless steel biomaterials have shown excellent resistance to breakdown & multiple examples of tissue & host compatibility have been shown for implants removed after long term implantation. Precautions: if stainless steel implant surfaces are mechanically altered during implantation or if the construct induces an interface that is subjected to biomechanical fretting, the iron alloy will biodegrade. g) Other Metals and Alloys Tantalum, Platinum, Iridium, Gold, Palladium and alloys of these metals have been used.More recently devices made from Zirconium, Hafnium and Tungsten have been evaluated. Precautions: Gold, Platinum and Palladium are metals of relatively low strength which places limits on implant design. But still Gold is used because of nobility and availability. 2. CERAMICS Ceramics are inert materials and have excellent biocompatibility

Based on their interaction with bone there are two types: a. Bioactive e.g. Hydroxy apatite and Bioglass b. Bioinert e.g. Aluminum oxide a) Ceramics and Carbon Ceramics are inorganic non metallic, non polymeric materials manufactured by compacting and sintering at elevated temperatures. Because of their inertness to biodegradation, high strength, physical characteristics such as color and minimal thermal and electrical conductivity, and a wide range material specific elastic properties they are in use. Ceramics have been used in bulk forms and more recently as coatings on metals and alloys. Precautions: The low ductility or inherent brittleness has resulted in limitations: b) Alumina, Titanium & Zirconium Oxides High ceramics from aluminum, titanium and zirconium oxides have been used for root form, endosteal plate form and pin type dental implants. The compressive, tensile and bending strength exceed the strength of the compact bone by 3-5 times. These properties combined with high moduli of elasticity and especially with fatigue and fracture strength have resulted in specialized design requirements. The Aluminium, Titanium and Zirconium oxide ceramics have a clear white, cream or light gray color which is beneficial for applications in anterior root form devices. In early studies of dental and orthopedic devices in laboratory animals and humans ceramics have exhibited direct interphases with bone similar to an Osseo integrated condition with Titanium.

Precautions: One series of root form and plate form devices used during the 1970s resulted in intra oral fractures after several years of function. The fractures were initiated by fatigue cycling where biomechanical stresses were along regions of localized bending and tensile loading. c) Bioactive and Biodegradable Ceramics Based on Calcium Phosphate The calcium phosphate ceramics used in dental reconstructive surgery include a wide range of implant types and thereby a wide range of clinical implications. The laboratory and clinical results for calcium phosphate particulates were most promising and led to expansions for implant application. Calcium aluminates, sodium lithium inert glasses with calcium phosphate and glass ceramics provide a wide range of properties and have found extended applications. Precautions: In general these classes of bio-ceramics have lower strength, hardness and modulus of elasticity than the more chemically inert forms previously discussed. d) Carbon & Carbon Silicon Compounds Carbon compounds are often classified under ceramics because of their chemical inertness & absence of ductility, however they are conductors of heat & electricity. Ceramic & carbonate substances continue to be used as coatings on metallic & ceramic materials. They show tissue attachment and provide Opportunities for the attachment of active biomolecules/synthetic compound. Precautions: They show lack of mechanical strength properties e) Hydroxy Apatite

In addition to bulk, aluminum oxide biomaterials, calcium phosphate based ceramic or ceramic like coatings have been added to Titanium & Cobalt alloy substrates to enhance tissue integration. These coatings for the most part are applied by plasma spraying small size particles of crystalline hydroxyapatite ceramic powders.43 Surface roughening by particulate blasting can be achieved by different media. Sandblasting provides irregular, rough surface of 10. Titanium implants maybe etched with a solution of Nitric acid and Hydrochloric acid. The acids very rapidly attack metals other than Titanium & these processes are electrochemical in nature. Precautions: Surface roughening is quite a sensitive procedure and requires much care and precision.

3. POLYMERS & COMPOSITES

It can be designed to match tissue properties, can be anisotropic with relation to mechanical characteristics, can be coated for attachment to tissues, can be fabricated at relatively low cost. a)Polymers In general, polymers have low strength & elastic moduli and higher elongations to fracture compared with other classes of biomaterials. They are thermal & electrical insulators and are relatively resistant to bio degradation. 44 Polymers have been fabricated in porous and solid forms for tissue attachment, replacement, augmentation & as coatings for force transfer to soft & hard tissue region. Cold flow

characteristics, creep & fatigue strengths are relatively low for some classes of polymers. e.g: Polymethylmethacrylate. In contrast some are extremely tough and fatigue cycle resistant. e.g: Polytetrafluoroethylene. The indications for Polytetrafluoroethylene have grown exponentially in the last decade because of the development of membranes for guided tissue regeneration technique. b)Composites Most of the inert polymers have been combined with particulate or fibers of carbon, Aluminum oxide, Hydroxyapatite & glass ceramics. In some cases, bio degradable polymers such as Poly Vinyl Alcohol, Poly Lactides or Glycolides, Cyanoacralates or other Hydra table forms have been combined with bio degradable CaPO4 particulate or fibers. These are intended as structural scaffolds, plates, screws or other such applications

TYPES OF IMPLANTS
1.BASED ON THE LOCATION a) Subperiosteal (fig 31) In this design, the implant body lies over the bony ridge. It has decreased long-term success rate because of increased chances of dislodgement and complex in their design. The Subperiosteal design currently in use for orthodontics is ONPLANT

Onplant developed by Block and Hoffman in 1995 consists of circular disc 8-10mm in diameter with a provision for abutments in center,through which orthodontist carry tooth movements against implants

Fig 31: Subperiosteal implants b) Transosseous(fig 32) The implant body penetrates the mandible completely. It is not widely used because of possible damage of the Infra bony soft tissue structures like the nerves and vessels.

Fig - 32: Transosseous implants c) Endosseous implants These implants are partially submerged and anchored It is most popular and most widely used one. within bone.

Fig 33-endosseous implants d) Denture Enhancing Intramucosal Implant

Intramucosal inserts differ in form, concept, and function from the other modalities. They are mushroom-shaped titanium projections that are attached to the tissue surface of a partial or total removable denture in the maxilla[14] and plug into prepared soft-tissue receptor sites in the gingiva to provide additional retention and stability. Thus, they provide support for a prosthesis but do not provide abutments. They are used in the treatment of patients for whom endosteal or subperi osteal implants are not deemed to be practical or desirable. Intramucosal inserts do not come into contact with bone, so the mode of tissue integration is not

osteointegration, osteopreservation, or periosteal integration. Rather, the receptor sites in the tissue into which the inserts seat become lined with tough, keratinized epithelium. In this sense, seated intramucosal inserts are external to the body. Only one appointment is required for the placement of intramucosal inserts. For reasons that are described in detail in Chapter 20 , intramucosal inserts are best used in the maxilla. Because of complicated biomechanics, more acute alveolar ridge angles, a wider array of applied forces, and insufficient gingival thickness, placement of intramucosal inserts in the mandible is not recommended. Figs. 2-31 and 2-32 show radiographs of typical mainstream intramucosal insert cases in the maxilla.

e) Osseousimplants These are placed in dense bone such as zygoma, body, ramus and palatal area.

2. BASED ON THE CONFIGURATION DESIG

A )Root form implants are designed to resemble the shape of a natural tooth root. They usually are circular in cross section. Root forms can be threaded, smooth, stepped, parallel-sided or tapered, with or without a coating, with or without grooves or a vent, and can be joined to a wide variety of components for retention of a prosthesis. As a rule, root forms must achieve osteointegration to succeed. Therefore, they are placed in an afunctional state during healing until they are osteointegrated. Semi-submerged implant healing collars are then removed, or submerged implants are surgically exposed for the attachment of components for the retention of a fixed or removable prosthesis. Thus, most root forms are twostage implants. Stage one is submersion or semi-submersion to permit afunctional healing ( , and stage two is the attachment of an abutment or retention mechanism Semi-submersion of root forms obviates the need for two surgical interventions, which represents an important improvement in the modality in terms of technique-permissiveness. Root form protocols require separate treatment steps for insertion and abutment or retention mechanism attachment whether the healing protocol calls for submersion or semi-submersion.

root

a)Screw Type Implant Tramonte introduced a stress resistant drive screw implant. Meglan & Lehman reported on the expandable implants. Later Lew introduced a self tapping Vitallium screw implant with conventional threads & square post. Muratori & Pasquallini introduced hollow cores along with the screw threads. The majority of these screw shaped implants were one piece & were not submerged, did not

osseointegrate. It was emphasized that the fibrous peri implant membrane with its shock absorbing feature preferred than bone fusing to implant. In 1963 Dr. Linkow, American Dentist developed first screw type of implant Vent Plant. This was the first self tapping, self threading implant. It had an open cage like design that went into bone first, with a few threads on solid body at the top. He used Vitallium first latter on titanium. b)Blade Implants (fig 34)14

Fig- 34:Blade implants

Linkow invented blade implants in 1967, long thin blade that will be surgically inserted into the groove in the bone.

Abutment projecting out from the blade to this crown or attachment for denture can be placed. It required the shared support of natural teeth also. It can be restored within month so became most widely used in united states.

Linkow modified the design configuration for broad applicability in maxilla & mandible, narrow ridges.

c) Ramus Frame Implant (fig 35)

Fig - 35: Ramus frame implants In 1970 Roberts & Roberts developed Ramus blade implants. It was to be positioned by anchoring distally between the cortical plates in the ramus of the mandible. The endosseous implant received stabilization from its anchorage in ramus area bilaterally & in the symphyseal region. Endodontic stabilizer Although endodontic stabilizer implants are endosteal implants, they differ from
other endosteal implants in terms of functional application. Rather than providing additional abutment support for restorative dentistry, they are used to extend the functional length of an existing tooth root to improve its prognosis[6] and when required, its ability to support bridgework. Modern endodontic stabilizers take the form of a long, threaded post that passes at least 5 mm beyond the apex of the tooth root into available bone. Endodontic stabilizers have been designed with parallel or tapered sides, smooth or threaded. The most successful endodontic stabilizers are threaded and parallel-sided, with sluiceways in the threaded crests that prevent apical cement sealant from being expressed into bone by guiding it crestally. The parallel-sided threaded design controls the stress concentration at the apex of the root, protecting against fracture and trauma. [7] The endodontic stabilizer functions in the osteopreservation mode of tissue integration, because the tooth root through which it is inserted is subjected to normal physiologic micromovement as it heals. Endodontic stabilizers are placed and the procedure is completed in one visit, as the final

step of any conventional endodontic regimen.

 3-OTHER DESIGNS OF IMPLANTS a) IMZ Implant System(fig 36)

Fig - 36: IMZ Implants Kirsch developed the IMZ implant system in 1974. Since 1978 its in clinical use. Its an intramobile cylinder endosseous two stage osseointegrated polyoxymethylene & polyacetal are used as IME. Its available in 3.5 to 4mm diameter and 8, 10, 13, 15mm length. Surface coating may be titanium plasma spray or plasma sprayed Hydroxy apatite coated surface. b)Lederman Screw Implant(fig 37)45 implant. The

Fig (37): lederman screw implant In 1977 Dr. Philippe Lederman in collaboration with strauman company developed the Titanium plasma spray screw type implant. In 1989 Lederman developed the New Ledreman screw implant surface roughened by sand blasting & acid etching. c) ITI Bone Fit Implant System(fig 38)

Fig (38) : ITI bone fit implant Developed by International Team for Implantology. Its of two different types- Single stage & two stage. Its Transgingivally placed in healing phase so second surgical procedure for uncovering the implant is avoided. d) The Hand-Titanium Implant System

Clinical use since 1985 in Switzerland & now in use world wide (Lederman 1986). Its a conical, step- screw, pure Titanium implant with self thread.

Length- 10 to 20mm. Diameter 3.5 to 7mm. In early 1980s Tantum introduced Omni R implant- A Titanium, root form implant with horizontal fins. He then introduced Omni S implant for placing into bone grafted maxillary sinus.

In 1983 EL Blasty & Kamel introduced the new endosseous implant material i.e. Poly acrylic acid reinforced with ceramic alumina particles 0.3 microns. The hydrophilic matrix swells in contact with aqueous solution. The gradual pressure on the surrounding bone stimulates osseous activity. It is Implanted in canine, premolar sites with promising results.

e) Mini Dental Implant(fig 39)

Fig - 39: Mini Dental Implant

In 1985 Victor Sendax developed MDI. It has an ultra small diameter of 1.8 mm, biocompatible Titanium alloy implant screws. Bulard added single one piece `O- ball design.

f) Core Vent implant(fig 40)45

Fig - 40: Core vent implant Developed by Dr. Gerald Niznick in 1986. Its a Hollow basket design made of Titanium alloy. It comes in different fixture designs - Screw Vent, Micro-Vent, Bio Vent. g) Endopore implant (fig 41)45

Fig - 41:Core vent implant

A root form dental implant developed by Doughlas et al in 1996 made of Titanium alloy & sintered with same alloy producing porous surface. It has Biological & clinical advantages over the other implants .

h) Steri Oss System45 It was Introduced by Denar. Its made up of 99.9% Ti, tapered apex thread design & the coronal 3rd highly polished surface. Its available in 3.5 to 4mm diameter, length 12 mm,16mm, 20mm,& mini series 8mm,10mm,12mm length. i) Novum Concept implant (fig 42)45,47

Fig- 42: Novum concept implant Branemark developed the concept of providing a new set of teeth for the mandible in a single day. It was clinically implicated in 1996. In this three titanium fixtures inserted, mucosa is closed & base plate is placed over the fixtures & then the prosthesis is placed. j) Zygomaticus Fixtures implants (fig 43)47

Fig(43): Zygomatic Fixture Implants In this the long fixture can be anchored in zygoma by approaching through the sinus. In used in cases with a severely resorbed maxilla. k) Bicortical Screw Implant(fig 44)45

Fig - 44: Biocortical Screw Implant Its a self tapping type of dental implant. It has a diameter of 2.5, 3.5, 4.5, 5.5mm and length of 21 -30mm. Post extraction insertion is done for single tooth replacement. l) Osteoplate 2000(fig 45)47

Fig - 45: Osteoplate 2000 implants Its used for atrophic residual alveolar ridge. Conical plate with shoulder width 1.3 mm & base 0.9 mm is used.