Oral Implantology

Oral Implantology
Dental Implants

• Definition:
– Dental Implants are prosthetic devices of alloplastic materials implanted
into the oral tissues beneath the mucosal and/or periosteal layer, and
on/or within the bone to provide retention and support for a fixed or
removable prosthesis.

· History Of Dental Implants

Replacement of lost dentition has been traced to ancient Egyptians, there are writings
about carved ivory teeth were the oldest examples of primitive implantology.

Today, implantology has gained a lot of popularity and allow greater number of patients
to enjoy the benefits of fixed restorations due to high rate of success achieved by;

1. Development of large number of implant systems with great variation in shape,

size, material and techniques.
2. Development of proper surgical techniques in preparation of osteotomy.
3. Development of extensive researches and clinical investigations by branemark
and coworkers for utilization of Osseointegration principle.

Osseointegration

• Osseointegration is defined by Branemark as “direct structural and functional

connection between ordered living bone and the surface of a load carrying
implant”
• For the dental implant to show long term success it has to bind to the surrounding
bone in which it is placed without an intervening soft tissue layer (fig.1)

Physiology of Osseointegration

The response of bone after implant placement:

• Clot formation. It is formed immediately after surgery at the implant-bone

interface (24 h.).
• By 3-5 days the clot begins to be replaced by granulation tissue rich in blood
vessels, and osteogenic Mesenchymal cells.
• Formation of bridging callus and lattice of woven bone by osteoblasts in 6 weeks.
 • The callus is gradually replaced by well-organized lamellar bone. This process
takes about 18 weeks.
• Remodeling and maximum compact lamellar bone interface is achieved
after implant loading within one year(fig.2)

Factors affecting the Success of Osseointegration:

1. Bio-compatibility→ bio-compatible material as titanium is necessary to promote

healing either the body rejection will occur by surrounding implant with
granulation tissue and connective tissue.

2. Implant design→Cylindrical implant are more stable than tapered one as it has
wide surface area for Osseointegration with bone.

3. Implant surface coating→Implant surface treatment creates micropores for

attachment and connection with bone.

4. Status of the bone→It is important to consider bone quality and quantity that
affect implant immobility.
5. Surgical technique→Atraumatic surgery allows minimal mechanical and thermal
injury to occur.
6. Loading conditions→Angular bone loss may be caused by occlusal trauma or
premature loading, lateral forces on the implants should be minimized as it has
destructive impact.

Criteria for implant success:

1. Adequate surgical and prosthodontic skill in implant placement and restoration.

2. Adequate size and biocompatible material of the implant to be inserted.
3. Adequate bone volume (height &width) with no peri-implant radiolucency when
examined radiographically.
4. Adequate primary stability of individual implant when tested clinically.
5. Absence of any signs and symptoms after implant insertion.
6. Vertical bone loss should not exceed 0.2 m.m per year after implant insertion and
function for first year.
7. At the end of 10 year period 80% of individually placed implants should be
successful in the context of the criteria.

Reasons for failure:

1. Improper implant placement.

2. Improper distribution of occlusal load (forces in lateral direction) that causes
damaging stresses.
3. Overheating bone during implant placement that result in fibrous tissue
against implant surface rather than bone.
4. Poor bone quality leading to lack of integration due to lack of bone formation.
5. Presence of infection that affect healing and integration result in early failure
after loading.
Implants are not indicated for every patient. Proper patient selection is mandatory
to achieve predictable results and high success rates.

Indications:

1. free end distal extensions where no posterior abutment is available.

2. Long edentulous span with questionable prognosis of fixed restorations
3. Unfavorable number and location of natural tooth abutment.
4. Single tooth loss.
5. Inability to wear removable partial denture for esthetics or for
psychological reasons.

Contraindications:

1. Uncontrolled metabolic diseases.

2. Tumoricidal radiation to implant site.
3. Elderly debilitating patients.
4. Bad oral hygiene of chronic periodontal disease.
5. Traumatic etiologic history of tooth loss.
6. Chronic steroid therapy.
7. Cardiovascular disease.
8. Lack of operator skill.
9. Improper motivation and unrealistic expectation of the patient.

Advantages of Dental Implants

i. Maintenance of the alveolar ridge height and width.
ii. Maintenance of masticatory efficiency and facial esthetics.
iii. Reduce the size of prosthesis by elimination of long flanges and
palatal coverage.
iv. Elimination of the need to alter adjacent teeth.
v. Allow the construction of fixed prosthesis in cases of free end saddles
or complete edentulous.
vi. Improve the stability and retention of removable prosthesis.
vii. Improve patient satisfaction and psychological health.

Disadvantages of Dental Implants

• The need for surgical intervention.

• Increase the time and cost of prosthetic replacement.
Implant Patient Selection:

The following criteria have to be carefully evaluated:

· Patient’s medical condition;

A review of past medical history can provide a wealth of information that will
exclude patients who are contraindicated for implant placement because there are
some diseases have bad effect on bone so it may prevent Osseointegration as ;
➢ Uncontrolled diabetes
➢ Hyperparathyroidism
➢ Chronic steroid therapy
➢ Anticoagulant patients
➢ Irradiation to the maxillofacial area
➢ Smoking
➢ Osteoporosis

· Evaluation of the alveolar bone:

I-Bone quantity

The residual alveolar ridge is classified into 5 Classes :( fig.3)

1. Adequate bone height and width

2. Adequate bone height and deficient bone width
3. Combined bone height and width deficiency
4. Total loss of the alveolar bone leaving only basal bone
5. Some resorption in the basilar bone

II-Bone quality (fig.4)

I. Type I “D1”: Almost the entire jaw is composed of homogenous compact

bone.
II. Type II “D2”: A thick layer of compact bone surrounds a core of dense
trabecular bone.
III. Type III “D3”: A thin layer of cortical bone surrounds a core of dense
trabecular one of favorable strength.
IV. Type IV “D4”: A thin layer of cortical bone surrounds a core of low
density trabecular bone.
Type II and type III are considered the most favorable for implant placement.
 · Dental Examination:

Careful dental examination should be done with assessment of oral hygiene, nature of
opposing teeth and accurately mounted diagnostic casts which are essential for evaluation
residual bone, study of remaining dentition and to evaluate available intermaxillary space
and maxillo-mandibular relationship.

• Radiographic examination:
Radiographic objectives:
– Evaluation of the available bone volume.
– Proximity to vital structures such as the inferior alveolar nerve, the
maxillary sinus and nasal cavity.
– Detection of any bony abnormalities or pathology.
– Evaluation of the proposed implant position in relation to the remaining
dentition or to other existing implants.
– Evaluation of bone quality.

• Radiographic techniques:

1. Periapical Radiograph;

It is excellent way to evaluate missing teeth, root angulation, size and

interproximal bone.

2. Panoramic Radiograph;

it is excellent screening examination to give broad perspective on inferior

alveolar canal, maxillary sinus, mental foramina and nasal floor. it is very useful in
single and multiple teeth replacement

3. C.T Scan ;

it may be helpful when full complement of implant is considered.(fig.5)

4. Dental Scan;

Interactive implant software programs

 It may be used to provide dimensional views of upper and lower jaws. It is very
useful in case of placement of an implant adjacent to vital structures.

Surgical Guide Template

• The surgical guide template should be part of every case since the implant
placement is permanent as it helps in transferring the preplanned implant position
and direction to the surgical field so it guide the surgeon during osteotomy
preparation and help him to gain parallelism in case of multiple implants and to
prevent vital structures injury.

Steps of construction;

1. Obtaining study models mounted on an articulator(fig.6)

2. Waxing up or setting up denture teeth in edentulous areas to simulate the final
prosthesis
3. Fabrication of either a clear acrylic self cured resin stent or a vacuform stent.(fig.7)
4. Identification of implant positions and its relation to the crest of the residual alveolar
ridge
5. Creation of guide holes in the exact implant positions and directions.

Stereo tactic (Stereo lithographic) Guide Template

Stereo lithography is one of a set of engineering technologies called Rapid Prototyping

which allows the fabrication of physical replicas of 3D computer generated models in a

layered approach. Software slices the file from top to bottom and then the slice data is

sent to a machine that fabricates the part slice by slice. (fig.8)

Computer Guided Surgery

CAD/CAM of Surgical Guides

o Limitations of anatomic structures sometimes cause prosthetic difficulties during
reconstruction.
o Today there are alternatives in the form of design/computer-assisted
manufacturing for creating precise surgical guides that allow for complete
integration of the diagnostic plan with the underlying anatomy.
o Computer software programs have been developed to provide the practitioner
with precise implant placement planning and to fabricate surgical guides.
 o CT scan is needed and conversion of that scan into a 3-dimensional (3D) image.
(fig.9)
Benefits of 3D image:
1. Makes it possible to find adequate bone for implant placement even where none is
expected.
1. It allows the practitioner to concentrate on the planning phase of treatment
2. It provides immediate function.
3. The patient benefits by a flapless surgical procedure, thus reducing swelling and
postoperative pain.
4. It reduces the number of patient visits
5. It decreases the dentist chair time for the eventual restoration.

Armamentarium

Component parts of implant system:

These are component parts typically necessary to restore a screw retained Osseo
integrated implant

1. Fixture (implant)
2. Cover screw
3. Abutment
4. Abutment screw
5. Prosthetic screw
6. Impression coping
7. Laboratory analogue
8. Healing abutment
9. Hand wrench
10. Screw drivers
11. Surgical drills
12. Paralleling pins

1. Fixture:
It is the portion that is designed to be surgically placed within bone.
It may be threaded or non- threaded
It may be made of titanium or titanium alloy
It may be with or without hydroxyl apatite coating. (fig.10)

2.Cover Screw:
It is used during healing phase to close connection between fixture and abutment. It is
usually low in profile to facilitate suturing of soft tissue inhibiting its in growth that
prevent abutment seal.
 3.Abutment:
It is the component that fits onto the fixture to be used as Tran mucosal extensions for
direct support of the prosthesis. It may be standard, fixed, angled tapered or non
segmental. (fig.11)

4.Abutment Screw
It is the components that connect the abutment to the fixture. (fig12)

5.Prosthetic Screw:
It is the component that connects superstructure (fixed restoration) to the abutment (in
case of screwed appliance).

6.Impression Coping:
It is the component that adapt on the fixture before impression taking to gain accurate
intra-oral location of the fixture and abutment in diagnostic casts.(fig.13)

7.Laboratory Analogue:
It is the component machined to resemble the fixture body in the diagnostic casts, after
impression taking the impression coping is then removed and joined with the laboratory
analogue to be placed in its accurate position in the impression.

8.Healing Abutment:(Collar)
It is the component placed after fixture placement and before prosthesis placement that
allow the gingival to heal according to gingival height around it.

9.Hand Wrench:
It is used for final sitting of the implant in the prepared osteotomy after insertion

10.Screw Driver:
It is used to handle the cover screw. It may wind or unwind with variable sizes and
shapes.

11.Surgical Drills:
They have marked gradual increasing diameter and length used for osteotomy preparation
and enlargement to be ready for implant insertion. (fig.14)

12.Paralleling pins:
They are used to help the clinician in preparation of parallel osteotomy holes. (fig.15)

Implant Types:
I. Subperiosteal (Eposteal) implants
II. Endosteal implants
 a. Transmandibular implants
b. Blade vent implants
c. Root form implants

I-Subperiosteal Implants:

It is cast metal framework that fits on the residual ridge beneath the periosteum held by
fibrous encapsulation and provides support for dental prosthesis by means of posts
protruding through the mucosa. (fig.16)
It is indicated in:
· Severely atrophied ridge by either taking direct impression of bone after exposure
or through 3D CT scan.

II-Endosteal Implants:
A-Transmandibular Implants:

It is stabilizing plate with projecting rods that is placed to the inferior border of the
mandible by extra-oral incision with its rods penetrating both cortical plates to project
from crest of the ridge after passing through full thickness of alveolar ridge .(fig.17)
It is indicated in:
· severely atrophic mandible,
· irradiated mandible
· poor prognosis of routine augmentation

B-Blade Vent Implants:

It is wedge shaped implant with vents through which tissue may grow and metal posts
projecting from this blade used for prosthesis connection. (fig.18)
It is indicated in:
· knife edge ridges

C-Root Form Implants: Classifiction:

· According to Shape:

1-Cylindrical
2-Tapered (fig.19)

· According to presence or absence of threads:

1-Threaded→ it is designed to engage bone by screwing into osteotomy to allow for
greater primary stability.

2-Non-Threaded→it is designed to engage bone by press-fit. it is useful in poor bone

quality.

· According to implant material:

1-Historical materials →include ceramics, polymers and carbons.

2-Titanium
→the mostly used material nowadays
3-Titanium alloy because they are the most
Biocompatible material.

4-zirconium oxide→achieve a lot of success recently.

· According to surface coating:

Surface Coating is used to increase surface area of the implant thus increasing the area of
contact between implant and bone for better ossieointegration.
It may be:
➢ Machined surface (regular untreated surface).
➢ Titanium plasma spraying (TPS).
➢ Surface blasting which can be done using non resorbable or resorbable materials.
➢ Acid etching.
➢ Hydroxyl apatite coating.
➢ Beaded surface.

According to Implant to Abutment attachment:

1-one piece implant→ the fixture and the abutment are fabricated as one piece.

2-two piece implant→the fixture and the abutment are fabricated separately.

According to connection between implant and abutment:

1-External connection:
-Hexagon -Spline

2-Internal connection:
-Hexagon -Conical -Octagon
Surgical protocol :(( Two-Stage Protocol):

Stage I: Implant Placement:

Planning for Implant Placement:

➢ Aseptic Protocol:

The surgical team, operating room and instruments to be used during operation should
follow strict aseptic protocol to prevent risk of contamination which may lead to implant
failure.
➢ Type Of Anesthesia:

-Local anesthesia is the mot commonly used type of anesthesia for implant placement.

-Conscious sedation may be beneficial in combination with local anesthesia because such
surgery require more time than other surgical procedure.

-General anesthesia may be used with patients who will have another surgical procedure
as sinus lift or bone graft.

➢ Surgical Phase: Stage I:

1. Surgical Flap Design:

Criteria of the flap design:

1-It should allow convenient retraction of soft tissue for adequate exposure during
implant placement.

2-It should preserve periosteal attachment by limitation of soft tissue dissection.

3-It should allow primary closure of the wound to preserve esthetics.

Simple crestal incision is the incision of choice, it should be placed slightly buccal or
lingual because it preserve facial contour and soft tissue bulk and to allow careful closure
of the incision away from the implant which is placed directly under the incision.

2.Preparation of the implant site:

 (Osteotomy hole)
Aim:
1- Careful surgical drilling to provide a precise bone osteotomy while preserving the
bone vitality.
1. Reduce heat generation as bone cells lose viability if subjected to
temperatures above 45°C.
How to Achieve that Aim?
1-Bone osteotomy should be done under copious internal and external irrigation
2-Light pressure applied to the drill
3-Low speed not exceeding 2000 rpm
4-The use of several successive sharp drills of increasing diameter

Procedures of surgical drilling for the implant:

1. After flap reflection, surgical guide template is positioned on

the residual ridge to assist in directing the angulations of the implant.

2-osteotomy is initially drilled by small diameter 2m.m drill (Pilot drill).

3-the initial preparation is sequentially enlarged to the desired implant dimensions using
series of rotary drills with increasing diameter and gradual depth markings.

4-in case of multiple implant placements, paralleling pin is placed in the initial
preparation to be a guide for drilling another osteotomy hole to insure parallelism
between implants.

5-after drilling procedures, the osteotomy should be well irrigated to remove any debris
before implant placement.

3.Implant placement:(fig.20)

According to type of implant:

• Non-threaded (Press-fit) implants:

– Implants are carried to the osteotomy hole and pressed in position
– Final seating is done by light tapping on the implant
• Threaded implants:
– Are either self tapping or need pretapping using a special tool
– Implants are screwed into position using hand wrench or engine driven
instruments.
4-Flap Closure

The flap should be sutured tightly without tension to prevent wound

dehiscence.
Implant exposure: stage II:

➢ Time necessary to achieve Osseointegration varies from site to site as:

In mandible →3-4 months

In maxilla→about 6 months

After this healing period: asmall incision is done over the implant, cover screw is
removed and healing abutment is placed to allow further prosthetic work steps.

Post operative care:

➢ Radiograph should be taken postoperatively to evaluate position and relation of the

implant with adjacent vital structures as inferior alveolar canal and maxillary sinus.
(fig.21)
➢ Patients should be provided by analgesics and chlorohexidine oral rinse.

Modification of surgical protocol

I-One stage technique:(non-submerged):

It is the same as two stage techniques except during flap closure; short healing abutment
is placed on the fixture and projects through the incision to allow tissue healing around it
for better esthetics.

advantages: no need for 2nd surgery

disadvantages:
1-increased risk of infection because of open access to the oral flora to the top of the
implant through the incision.

2-the implant will take partial amount of loading during mastication.

· Then the healing abutment will be discarded and replaced by an abutment or

using one piece implants instead of classical two piece implants.

advantages of one piece implant:

1-easy insertion and restoration.
2-possibility of using small diameter implants in narrow ridges.
3-lack of micromovements between the fixture and the abutment.

disadvantages:
1-limited prosthetic options because of inability to modify abutment angulations.
II-Immediate implant placement :

Instead of allowing healing period of socket for about 4-6 months after tooth extraction,
implants can be placed in fresh extraction sockets.

Advantages:
Decrease time during which the patient is edentulous or with temporary prosthesis.

➢ When using this principle, spaces between the fixture and the socket walls should be
filled with bone graft or using guided bone regeneration.
III-Delayed-Immediate Implant Placement
After tooth extraction, implant placement is delayed for 2-4 weeks to allow for soft
tissue healing.

IV-Flapless Implant placement:

Drilling osteotomy hole can take place through the mucosa or after the use of tissue
punch instead of raising mucoperiosteal flap.
Tissue punch is a device to cut around hole in the gingiva adequate in diameter to the
size of the implant to be used.
It necessitates fabrication of 3D model for the patient's jaws depending on dental C.T
scan to which surgical guide is placed.
Requirements: 1-adequate attached tissue.
2-implant can be palpated.

Advantages:
1-least traumatic
2-decrease operating time
3-decrease postoperative pain and swelling
4- Ability to take early impression

Disadvantages:
1-inability to visualize bone anatomy during drilling.
2-inability to visualize implant and superstructure interface.
3-increase incidence of cortical perforation
4-difficulty to obtain external irrigation to the surface of the drill.
5-sacrifice attached tissue.

Implant site development and preservation:

I-Bone grafting:

• Types of bone grafts:

– Autogenic grafts: Bone harvested from the same host. For example bone
harvested from the iliac crest, the symphysis, the maxillary tuberosity or the
retromolar area.
 – Allogenic grafts: Bone transplanted from the same species.
– Xenogenic grafts: Bone transplanted form species other than humans.
– Alloplastic grafts: Synthetic biocompatible materials.

Forms of bone grafts:

– Block form to increase alveolar ridge width and/or height.
– particulate forms may be used to fill bone defect or gaps between the implant and
the osteotomy

II-Cortical onlay bone graft:

Indications:
1. To increase the width of the alveolar ridge. The bone graft is usually obtained
from the retromolar area or the chin and fixed in place using bone screws.

III-Sinus lifting:
After tooth loss, alveolar bone resorption occur accompanied by sinus enlargement
leading to insufficient bone for placement of implant of proper length.so, sinus floor
augmentation can be done either:
1- Lateral (open) approach (lateral wall of maxillary sinus) (fig.22)
2-Internal (closed) approach (through the implant osteotomy site using specially designed
osteotomes)(fig .23).

IV-Ridge splitting:
Indications: inadequate width of the residual ridge with some spongy bone
between two cortical plates.
-It can be done by application of bone graft in the split area between the two
cortical plates.
-Implants can be placed either immediately or after healing of the bone graft.

V-Distraction Osteogenesis
Indications: inadequate height and\or width of the residual ridge.
-Intra-oral distractor is used for gradual bone lengthening or widening after making
necessary osteotomy cuts (fig.24).
Advantages:
1-development of new bone result when osteomized segment of bone is slowly moved
allowing new bone formation in the gap.
2-very good way to gain large vertical increase of soft and hard tissue.

Disadvantages:
1-increased cost of distraction device.
2-esthetic compromising during distraction phase.
 Complications

General Complications:

a. Swelling
b. Pain
c. Infection
d. Bleeding and haematoma
e. Flap dehiscence

Specific Complications:
1. Nerve injury
2. Perforation into the maxillary sinus
3. Cortical bone dehiscence and perforations
4. Implant displacement
5. Bone fracture
1. Basal bone fracture
2. Alveolar bone fracture
6. Fixture malalignment and mal-positioning

Failure of Dental implants:

Implant failure occur at three distinct times,

I-Time of fixture insertion&primary healing:

A few implants will fail to integrate due to:

1-Lack of primary stability;

Due to failure to achieve precise implant fit or due to poor bone quality.

2-Flap dehiscence;
Due to postoperative infection or wound healing problems with exposure of the implant
to oral flora.

3-Bone over-heating;
Due to very high speed or increased pressure on the drill causing death of bony cells
around implants.

II.Time of Abutment Connection :

Failure of implants in this stage is associated with:
 1. Poor Osseoinregration;
Due to poor bone quality

2-Overloading;
Due to excessive biomechanical forces on the implant.

II. Time of Follow up period:

Failure of implants at this stage is rare and caused by:
1. Gingivitis ;
Due to very poor oral hygiene and plaque accumulation leading to progressive marginal
bone loss.

2. Fistula;
Due to improper tightening of the abutment screw leading to growth of granulation
tissue at the fixture interface resulting in mobility of the abutment and exposure of the
fixture to the oral flora.

3. Exposed threads;
Due to plaque accumulation and marginal bone loss, implant threads will be exposed to
the oral flora, it should have periodontal treatment and grinding off the exposed threads
by special drills to eliminate retention areas of plaque and food debris.

4. Fracture of abutment screw;

-it should be tightened using hand wrinch,
-If the torque is too little →screw become liable to fracture on biting
-If the torque is too high→screw head gets stretched and shears off during implant
loading.
-Lack of passive fit of prosthetic components cause screw fracture
-Lateral loading on the implant cause screw fracture.

5. Fracture of the fixture;

It is very rare complication and treated by removal of the broken implant.
It is evident firstly as rapid marginal bone loss in follow up radiograph.
Causes:
a-excessive loading
b-improper fit of prosthetic component
c-faulty implant design
d-patient with bruxism
e-implants with very deep and wide internal connection.