CHAPTER 10
Osseointegration
Michael S. Block DMD
Ronald M. Achong, DMD, MD
History of Dental Implants
Replacement of lost dentition has been
traced to ancient Egyptian and South Amer-
ican civilizations.' In ancient Egyptian writ-
ings implanted animal and carved ivory
teeth were the oldest examples of primitive
implantology. In eighteenth and nineteenth
century England and colonial America,
poor individuals sold their teeth for extrac-
tion and transplantation to wealthy recipi-
ents.- The clinical outcomes of these trans-
planted dentitions were either ankylosis or
root resorption. Continued research pro-
longed allotransplant survival but did not
appreciably improve predictability.
In 1809 Maggiolo placed an immedi-
ate single-stage gold implant in a fresh
extraction site with the coronal aspect of
the fixture protruding just above the gin-
giva.-^ Postoperative complications includ-
ed severe pain and gingival inflammation.
Since then various implant materials were
used ranging from roughened lead roots
holding a platinum post to tubes of gold
and iridium.^"^ Adams in 1937 patented a
submergible threaded cylindrical implant
with a ball head screwed to the root for
retention for an overdenture in a fashion
similar to that done today.""
Up to this point implant success was
marginal with a maximum longevity of only
a few years. Strock placed the first long-term
endosseous implant at Harvard in 1938.'*
This implant was a threaded cobalt-
chrome-molybdenum screw with a cone-
shaped head for the cementation of a jacket
crown. The implant remained stable and
asymptomatic until 1955, at which time the
patient died in a car accident. Strock wrote,
"The histological sections of implants in the
dog study showed remarkable complete tol-
erance of the dental implant and the pathol-
ogist report so indicated to our gratifica-
tion." Strock demonstrated for the first time
that metallic endosteal dental implants were
tolerated in humans, with a survival rate of
up to 17 years.^
Due to inadequate alveolar bone height
in certain sites of the jaws, subperiosteal
implants were developed. In 1943 Dahl
placed a metal structure on the maxillary
alveolar crest with four projecting posts.^
Multiple variations to this initial design
were fabricated but these devices often
resulted in wound dehiscence. Blade
implants were introduced by Linkow and
by Roberts and Roberts.'"" There were
numerous configurations with broad appli-
cations, and the implants became the most
widely used device in implantology in the
United States and abroad (Figure 10-1).
A two-staged threaded titanium root-
form implant was first presented in North
America by Branemark in 1978.'- He
showed that titanium oculars, placed in
the femurs of rabbits, osseointegrated in
the femurs of rabbits after a period of
healing. Two-staged titanium implants
were first placed in patients in 1965 and
studies showed prolonged survival, free-
standing function, bone maintenance, and
significant improvement in benefit-to-risk
ratio over all previous implants.'^ This
breakthrough has revolutionalized max-
illofacial reconstruction. Subsequently,
various implant designs have been manu-
factured and research in implantology has
grown exponentially. The frontiers of
implantology are rapidly being advanced
and esthetics continue to be an integral
part of this progress.
Implant Materials and Surface
Implant materials have undergone a num-
ber of different modifications and devel-
opments over the past 40 years. Commer-
cially pure titanium has excellent
biocompatibility and mechanical proper-
ties. When titanium is exposed to air, a
2 to 10 nm thick oxide layer is formed
immediately on its surface.^^ This layer is
bioinert. However, strength issues with
pure titanium have led manufacturers to
use a titanium alloy to enhance strength
of the implant. Most abutments are made
of titanium alloy. The use of alloy signifi-
cantly increases strength, which can be an
issue with small-diameter and internal
connections. Titanium alloy (Ti-6A1-4V)
is becoming the metal of choice for
endosseous dental implants.
190 Part 2: Dentoalveolar Surgery
Several attempts have been made to
improve implant anchorage in bone by
modifying the surface characteristics of
titanium implants {Figure 10-2). In order
to enhance the bone connection to the
implant, a thin coating of hydroxylapatite
(HA) has been plasma-sprayed onto a
roughened and prepared titanium implant.
HA coatings usually range from 50 to
70 |im and are applied to the implant sur-
face with plasma-spray technology.'^ A
pressurized hydrothermal postplasma-spray
increases the crystalline HA content from 77
to 96%, with an amorphous content of 4%.
This coating offers an improved bone adhe-
sion as shown in several studies.'^''^
Because of the success in orthopedics
with roughened titanium surfaces for
endosteal appliances, dental implant man-
ufacturers have modified the titanium sur-
face either by adding titanium to the sur-
face through plasma-spray technology or
by reduction procedures involving etching
and blasting the surface. The titanium
plasma-sprayed surface was the first rough
titanium surface introduced into implant
dentistry. The titanium plasma-sprayed
(TPS) surface process is characterized by
high-velocity molten drops of metal being
sprayed onto tbe implant body to a thick-
ness of 10 to 40 lim.^" Its original intent
was to obtain a greater surface area for
FIGURE 10-1 A, Blade implants. B, Subperiosteal
implant. C, Threaded implants with smooth tita-
nium or hydroxylapatite-coated surface.
C have been documented which are believed
bone attachment. TPS implants demon-
strated satisfying long-term results in fully
and partially edentulous patients.
Roughened titanium surfaces can also
be produced by reduction techniques such
as sand- or grit-blasting, titanium oxide
blasting, acid etching, or combinations of
these techniques. In 2000 Cordioli and col-
leagues reported mean bone-to-implant
A
contact values at 5 weeks of 72.4% for the
acid-etched surface, 56.8% for TPS, 54.8%
for grit-blasted, and 48.6% for machined
surface implants.'^ Reduced healing times
to result in the need for less time from
implantation to loading and better results
in poorer-quality bone.^"
Despite the success with machined
smooth titanium implants, the use of a
roughened surface has been substituted by
all manufacturers and clinicians as the
current surface of choice. With rare excep-
tions most endosseous implants have a
roughened surface texture.
Surgical Protocol Generic
for All Implants
Placement without Trauma to
the Soft and Hard Tissues
Heat generation during rotary cutting is one
of the important factors influencing the
development of osseointegration. It is wide-
ly accepted that heat increases in proportion
to drill speed, and that by extension.
FIGURE 10-2 A, Titanium plasma-sprayed sur-
face at high magnification. B, Acid-etched tita-
nium surface at low magnification. C, Hydroxyl-
apatite-coated surface at low magnification.

high-speed drilling causes physiologic
damage to bone. In 1983 Eriksson and
Albrektsson demonstrated the occurrence
of irreversible histologic damage in the
rabbit tibia when heat exposure at a tem-
perature of 47°C was longer than
I minute.'' An even greater injury
occurred after heating the bone to 53°C for
1 minute, and heating to temperatures of
60°C or more resulted in permanent cessa-
tion of blood flow and obvious necrosis
that showed no sign of repair over follow-
up period of 100 days.^'
Minimal heat during implant site
preparation has been recommended to
achieve optimal healing conditions.
Although the relationship between speed
and heat generation is still under debate,
the consensus has been to recommend
speeds of less than 2,000 rpm with copious
irrigation for preparation of implant sites.^'
In 1986 Eriksson and Adell showed that the
Branemark drilling system had a mean
maximum temperature of 30.3°C during
drilling, with a maximum temperature of
33.8°C.-^ The duration of maximum tem-
perature never exceeded 5 seconds.
Watanabe and colleagues measured
heat distribution to the surrounding bone
with three different implant drill systems,
in 1992.^^ Generation of heat in the pres-
ence or absence of irrigation when driUing
with spiral or spade-type drills was
observed in the pig rib via thermography.
The maximum temperature generated
without irrigation was significantly greater
than with irrigation for each drill. The heat
generated continuously spread to the sur-
rounding bone even after the bur or drill
was removed from the bone, and the origi-
nal temperature returned in about 60 sec-
onds. The spiral drill required the longest
time to generate heat, with gradual increase
of temperature. The round bur and cannon
or spade drill could finish cutting in a short
time, with rapid generation of heat. Maxi-
mum temperature without irrigation was
higher than with irrigation for any drill.
With irrigation at proper speed, minimal
heat was generated. When cortical bone was
prepared using the spiral drill, irrigation
decreased the maximum temperature by
10°C or more. It is recommended by all
manufacturers that the bur be moved up
and down while preparing the implant site,
to allow accessibility of irrigation to the
cutting edges of the bur, neutralizing heat
generation and removing bone debris.
Time for Integration
Historically a nonloading healing period
of machined-surfaced dental implants has
been 4 to 6 months for the mandible and
6 months for the maxilla."'' The 4- to
6-month recommendations were made to
prevent the development of a fibrous
encapsulation of the implant fixtures that
occurs witb premature loading. These
early recommendations for implant surgi-
cal protocol were developed based on clin-
ical observations and not necessarily based
on an understanding of the biologic prin-
ciples of implant integration. The original
Branemark protocol has been greatly
modified due to the advances in implant
microtopographic surfaces and design. In
recent years histologic and experimental
studies have shown that specifically
designed microtopographic implant sur-
faces can result in increased bone-to-
implant contact at earlier healing times
than obtained with machined-surface
implants. Over the years histologic and
clinical studies investigating early and
immediate implant loading revealed that
implants can be placed into function earli-
er than previously recommended. In 1998
Lazzara and colleagues evaluated the effi-
cacy of loading Osseotite dental implants
at 2 months to determine the effect of
early loading on implant performance and
survival.'-'' The cumulative implant sur-
vival rate was 98.5% at 12.6 months. The
cumulative postloading implant survival
rate was 99.8% at 10.5 months. Testori and
colleagues investigated the clinical out-
come of 2 months of loaded Osseotite
implants placed in the posterior jaws, with
Osseointegration 191
a follow-up period of 3 years.^^ The over-
all cumulative implant survival rate after
functional loading was 97.7% in the
mandible and 98.4% in the maxilla. Coop-
er and colleagues investigated the early
loaded implants in clinical function with-
out risking the result of osseointegration.-''
They demonstrated a 96.2% implant sur-
vival rate with loaded unsplinted maxil-
lary anterior single-tooth implants
3 weeks after one-stage surgical place-
ment."'' The majority of the tapered
threaded implants were placed in type
3 bone with a minimal length of 11 mm.
The mean change in marginal bone level
was 0.4 mm with a mean gain in papilla
length of 0.61 mm at 12 months. In a
recent report unsplinted implants placed
by a single-stage procedure were successful
when loaded by a mandibular overdenture
prosthesis."'^ Eurther developments in
implant surfaces will greatly reduce inte-
gration time (Eigure 10-3).
Key Reasons for Eailure
Endosseous dental implants have been
used successfully throughout the past few
decades. Unfortunately implants are not
always successful. Improper implant
placement can result in a framework
design that compromises esthetics and
distribution of force on implants.
Endosseous implants distribute occlusal
load best in an axial direction, but if the
occlusal load is in a lateral direction, many
damaging stresses, including shear stress-
es, are generated directly at the crest of
bone. Lazzara proposed that off-angle
implant positioning requiring over 25" of
angle correction will cause an implant
to fail.''' Overheating bone during place-
ment will result in a fibrous tissue against
the implant surface rather than the bone.
Placing implants into bone of poor quah-
ty without consideration to the mechani-
cal forces of loading can result in early
or late failure. Lack of hone contact at
the time of placement is also a factor lead-
ing to lack of integration or marginal
192 Part 2: Dentoalveolar Surgery
Smooth HA-coated
machined
titanium
FIGURE 10-3 Chart showing relative healing times for different implant surfaces. HA = hydroxylap-
atite; SLA type = sandblasted and acid-etched.
integration. The presence of infection
when placing an implant can lead to sub-
optimal healing and eventual lack of inte-
gration, infection within a week of place-
ment, or lack of bone formation that
results in early failure after loading.
Keratinized gingiva has been shown to
promote soft tissue health around teeth.
However, around dental implants, the pres-
ence of keratinized gingiva may or may not
be important for preservation of crestal
bone. Krekeler and colleagues suggested
that there is a strong correlation of kera-
tinized gingiva with implant failure and the
absence of an adequate band of keratinized
mucosa surrounding the abutment.-"' This
suggested relationship was based on the
ability of the keratinized mucosa to with-
stand bacterial insult and ingression, which
can lead to periimplantitis.
Clinical trials with HA-coated
implants indicate that the presence of ker-
atinized gingiva is important for long-
term success of endosseous implants.
There was a significant relationship
SLA Osseotite
ITI System
between implant survival and crestal bone
level maintenance with posterior
mandible implants in the presence of a
1 to 2 mm thick band of attached kera-
tinized gingiva.^' The early Branemark
reports indicate that crestal bone levels
were not affected by the presence of kera-
tinized gingiva in the anterior mandible,
although the presence of transient gingivi-
tis was increased in patients without the
protective effect of keratinized gingiva.
Thus, keratinized gingiva is important for
overall periimplant health.^' Procedures to
create and preserve keratinized gingiva are
recommended when placing and exposing
implants. When placing a one-stage
implant, incision design should result in
keratinized gingiva labial to the implant.
The most important factors for implant
success, identified by Block and Kent in
1990, are surgery without compromise in
technique, placing implants into sound
hone, avoiding thin bone or implant dehis-
cence at the time of implant placement,
established balance restoration, and ensur-
ing appropriate follow-up hygiene care.''
Implants placed into thin ridges or that had
dehiscence of their surface did not uniform-
ly gain bone attachment levels during the
healing period. Labial bone implant defects
should be grafted with particulate hydroxyl-
apatite. In the posterior maxilla, vertical
bone loss seems to be due to excessive
cantilever-type forces placed on the
implants. The use of sinus grafting is recom-
mended to provide adequate bone support
in the atrophic posterior maxilla. The pres-
ence of keratinized gingiva strongly correlat-
ed with bone maintenance in the posterior
mandible. Consequently, implant surgical
techniques should preserve all keratinized
gingiva. Most patients who receive implants
for dental restorations have lost teeth due to
caries or periodontal disease. Patients need
to maintain meticulous oral hygiene. If
pocket probing greater than 3 mm around
the implant occurs, additional antibacterial
solution application or pocket elimination is
recommended for hygiene purposes.
Wound Healing
Bone healing is a physiologic cascade of
events in which complex regenerative
processes restore original skeletal structure
and function. Bone is generated by two
separate mechanisms: endochondral and
membranous bone formation. Endochon-
dral bone formation occurs at the epiphy-
seal plates in long bones and condylar head
of the mandible and accounts for growth
in length."*' It entails the laying down of a
preformed cartilaginous template, which is
gradually resorbed and replaced by bone.
Membranous bone formation or primary
bone healing requires differentiation of
mesenchymal cells into osteoblasts, which
produces osteoid. The osteoid is then min-
eralized to form bone.^'^ This type of bone
formation occurs in the calvaria, most
facial bones, the clavicle, and the mandible.
Osseointegration belongs to the category
of primary bone healing. The word
osseointegration was defined as "a direct
structural and functional connection

between ordered, living bone and the sur-
face of a load carrying implant."^^
Wound healing consists of three fun-
damental phases: inflammation, prolifera-
tion, and maturation. The induction of
bone formation at surgical interfaces
reflects a major alteration in cellular envi-
ronment. These crucial events involve an
inflammatory phase, a proliferative phase,
and a maturation phase.
Phase One: Inflammatory Phase
Bone healing around implants results in a
well-defined progression of tissue
responses that are designed to remove tis-
sue debris, to reestablish vascular supply
and produce a new skeletal matrix. Platelet
contact with implant surfaces causes liber-
ation of intracellular granules that, when
released, are involved in the early events
associated with tissue injury." Release of
adenosine diphosphate, serotonin, prosta-
glandins, and thromboxane A2 promotes
platelet aggregation, resulting in a hemo-
static plug. Platelets continue to degranu-
late during the formation of the hemosta-
tic plug and release constituents that
increase vascular permeability (serotonin,
kinins, and prostaglandins) and con-
tribute to the inflammatory response
accompanying tissue injury.'^
Acute wound healing consists of a cel-
lular inflammatory response dominated
mainly by neutrophils. Migration of the
neutrophils to the site of injury generally
peaks during the first 3 to 4 days following
surgery.^"* These cells are attracted to the
local area by chemotactic stimuli and then
migrate from the intravascular space to
the interstitial space by diapedesis. The
role of these cells is primarily phagocytosis
and digestion of debris and damaged tis-
sue. Digestion of tissue is feasible via the
release of digestive enzymes such as colla-
genase, elastase, and cathepsin.^'' By the
fifth day macrophages predominate and
remain until the reparative sequence is
completed.^" These cells are derived from
circulating monocytes that originate from
the bone marrow via monoblast differenti-
ation. Macrophages can be activated by
products of activated lymphocytes and the
complement system. Macrophages have
the ability to ingest inflammatory debris
by phagocytosis and to digest such parti-
cles by releasing hydrolytic enzymes.^^
Phase Two: Proliferative Phase
Microvascular ingrowth from the adja-
cent bony tissues during this phase is
called neovascularization.'^ Cellular dif-
ferentiation, proliferation, and activation
result in the production of an immature
connective tissue matrix that is later
remodeled. The local inflammatory cells
(fibroblasts, osteoblasts, and progenitor
cells) proliferate within the wound and
begin to lay down collagen.^"^ This combi-
nation of collagen and a rich capillary
network forms granulation tissue with a
low oxygen tension. This hypoxic state,
combined with certain cytokines such as
basic fibroblast growth factor (bFGF) and
platelet-derived growth factor, is respon-
sible for stimulating angiogenesis. bFGF
seems to activate hydrolytic enzymes,
such as stromelysin, collagenase, and plas-
minogen, which help to dissolve the base-
ment membranes of local blood vessels.-^^
Reestablishment of local microcirculation
improves tissue oxygen tension and pro-
vides essential nutrients necessary for
connective tissue regeneration.
Local mesenchymal cells begin to dif-
ferentiate into fibroblasts, osteoblasts, and
chondroblasts in response to local hypoxia
and cytokines released from platelets,
macrophages, and other cellular elements.^'^
These cells begin to lay down an extracellu-
lar matrix composed of collagen, gly-
cosaminoglycans, glycoproteins, and glyco-
iipids. The initial fibrous tissue and ground
substance that are laid down eventually
form into a Bbrocartilaginous callus. The
initial bone laid down is randomly arranged
(woven type) bone.^'' Woven bone forma-
tion clearly dominates wound healing at this
point for the first 4 to 6 weeks after surgery.
Osseointegration 193
Phase Three: Maturation Phase
After the establishment of a well-
vascularized immature connective tissue,
osteogenesis continues by the recruit-
ment, proliferation, and differentiation of
osteoblastic cells.'^ Differentiated
osteoblasts secrete a collagenous matrix
and contribute to its mineralization.
Osteoid-type bone within a vascularized
connective tissue matrix becomes
deposited at dental implant surgical
interfaces.'^ Eventually this matrix
envelops the osteoblastic cells and is sub-
sequently mineralized. This cell-rich and
unorganized bone is called woven bone.
Loading of the dental implant stimulates
the transformation of woven bone to
lamellar bone.'*' Lamellar bone is an
organized bone displaying a haversian
architecture. Bone remodeling occurs
around an implant in response to loading
forces transmitted through the implant to
the surrounding bone. The lamellae
around the implant are remodeled
according to the exposed load, which
with passage of time, shows a characteris-
tic pattern of well-organized concentric
lamellae with formation of osteons in the
traditional manner.'^
Under normal circumstances healing
of implants is usually associated with a
reduction in the height of alveolar margin-
al bone. Approximately 0.5 to 1.5 mm of
vertical bone loss occurs during the first
year after implant insertion.^^ The rapid
initial bone loss is attributed to the gener-
alized healing response resulting from the
inevitable surgical trauma, such as
periosteal elevation, removal of marginal
bone, and bone damage caused by drilling.
Options for the Edentulous
Mandible
Options for patients with an edentulous
mandible include a conventional denture,
a tissue-borne implant-supported pros-
thesis, or an implant-supported prosthesis
(Figure 10-4).
194 Part 2: Dentoalveolar Surgery

Radiologic Examination of the

Edentulous Patient
Radiologic evaluation of the patient prior
to placing implants is focused on the
determination of vertical height and the
slopes of the cortices in relation to the
opposite arch. A panoramic radiograph is
the baseline radiograph used to evaluate
the implant patient. The lateral cephalo-
gram is useful to demonstrate the slopes
of the cortices of the anterior mandible
and the skeletal ridge relationships of the
mandible to the maxilla, and to provide a
simple and inexpensive radiographic
assessment of anterior alveolar height.
Additional radiographic techniques
include the use of complex motion
tomography or reformatted computed
tomography (CT) scans. CT has a less
than 0.5 mm error when reformatted
cross-sectional images are examined. As
clinical experience increases most sur-
geons agree that there is less need for
these more expensive radiographic tech-
niques for preparation of placing
implants. CT scans are becoming popular
in combination with models of the bone
for accurate treatment planning and the
F
fabrication of final prostheses prior to the
FIGURE 10-4 A, Two-implant bar for clip overdenture retention. B, Two-implant locator for overdentureactual surgical procedure.
retention. C, Hybrid prosthesis retained by five implants. D, Panoramic radiograph showing position of
five implants for hybrid prosthesis. E, Milled bar for fixed/removable prosthesis. F, Inner aspect of pros- Incision Design Considerations
thesis showing metal substructure with plunger attachments. G, The patient pushes the plunger attach-
ments to engage the milled bar and thus retains the prosthesis to the bar. C, D reproduced with permis- Based on the location of the muscle
sion from Block MS. Color atlas of dental implant surgery. Philadelphia (PA): W.B. Saunders Company, attachments and the height of the
2001. p. 5.
mandible, the surgeon makes the deci-
sion regarding which incision to use to
expose the bone and subsequently place
Physical Examination of the mine subsequent implant location. In a implants into the edentulous mandible.
Edentulous Patient relaxed vertical position of the jaws, the If the attachment of the mentalis muscle
The depth of the vestibule and the mental- relationship of the anterior mandible to is 3 mm or more labial to the location of
is muscle attachments are noted to deter- the maxilla is observed to determine the the attached gingiva on the alveolar
mine the necessity of a vestibuloplasty. benefits of positioning the implants to crest, a crestal incision can be used. If
The width of keratinized gingiva on the correct or mask a Class II or Class III the mentalis muscle is in close proximity
alveolar crest and the distance from the skeletal jaw relationship. Alveolar ridge to the alveolar crest, resulting in mobile
alveolar crest to the junction of the palpation will determine the slopes of the unattached gingiva directly against the
attached and unattached mucosa are labial and lingual cortices and the alveolar implant abutment, a "lipswitch" vestibu-
noted. Identification of the mental fora- height. The location of the genial tubercles loplasty is performed to inferiorly repo-
men by digital palpation is usefial to deter- should also be noted. sition the muscle attachments.

Two Implants
In general, when placing two implants for
an overdenture, one should take into con-
sideration the potential need for addition-
al implants at a later time. Some patients
enjoy the overdenture prosthesis but may
complain of food getting caught under the
denture, mobility of the prosthesis when
speaking, swallowing, or chewing, and a
desire to eliminate changing clips, O rings,
or locator-type attachments. These
patients may then desire the retention of a
fixed or fixed-removable prosthesis. For
these patients three additional implants
may be placed to result in a total of five
implants in the anterior mandible, which
is sufficient to support an implant-borne
prosthesis. Taking this into consideration
when placing two implants into the anteri-
or mandible, locating the implants 20 mm
apart, each 10 mm from the midline of the
mandible, allows for later implant place-
ment if needed.
Implant placement at the correct
height in relation to the alveolar crest is
crucial. If the implant is placed such that
the cover screw is superficial to the adja-
cent bone, a chance of incisional dehis-
cence or mucosal breakdown may occur. It
is advantageous to countersink implants
in the anterior mandible sufficiently {1 to
2 mm depending on the type of external
or internal connection of the specific
implant used) to allow the height of the
cover screw to be in a flush relationship
with the adjacent alveolar bone. The sur-
geon should follow the guidelines for the
specific implant system being used. For
one-stage implants temporary healing
abutments are placed as recommended by
the manufacturer. Accidental loading from
poorly relined dentures can lead to trauma
to the implants and eventual loss. Thus it
is prudent to excessively relieve and use
appropriate soft liners for the transitional
denture during the healing period.
The anterior mandible may have a
dense cortical plate with an abundant
marrow space, or it may have very mini-
mal marrow with an abundance of corti-
cal bone. The smaller the mandible, the
more cortical bone and less cancellous
hone is available. When encountering
very dense bone it is important to period-
ically clean the drill bits to keep the cut-
ting surfaces clean of debris during the
preparation of the implant site. For coat-
ed implants a threadformer type of bur is
used to create threads in the bone. For
self-tapping implants the surgeon may
need to use a slightly larger bur than is
customarily used in other areas of the
mouth. For example, rather than using a
3.0 mm bur prior to self tapping a
3.75 mm implant, a 3.25 mm diameter
drill may be necessary to allow for ease of
implant insertion into very dense bone.
Four or More Implants
Four or more implants are placed when
considering an implant-borne prosthesis.
Implant-borne prostheses include hybrid
screwed-retained, crown-and bridge type,
or fixed/re movable with milled bars and
retentive devices {see Figure 10-4). The
incision design is similar for placement of
four or more implants into the anterior
mandible. The subperiosteal reflection
should be sufficient to expose the lingual
and labial cortices and the mental foramen
bilaterally. After the periosteal reflection is
completed, the surgeon has an exceUent
view of the operative site, the contours of
the bone, and the location of the mental
foramen. A caliper is used to mark the
alveolar ridge at no less than 5 mm anteri-
or to the mental foramen. This distance is
usually the anterior extent of the nerve, as
it loops forward in the bone prior to exit-
ing the bone at the mental foramen. A
small round bur is used to place a depres-
sion in the bone to locate the implant site
on one side of the mandible. A similar
mark is placed on the opposite side of the
mandible, no less than fivemm anterior to
the mental foramen. The caliper is then set
to 7 or 8 mm and the next implant loca-
Osseointegration 195
tions are marked in a similar manner ante-
rior to the two distal locations. If a fifth
implant is to be used, then a mark is made
in the midhne of the mandible. By using
the caliper, the implant bodies are placed a
sufficient distance apart to ensure ade-
quate space for restoration and hygiene.
The use of CT-generated models of the
mandible can result in surgical templates
that can be secured to the jaws with pins or
the implants themselves, resulting in pre-
cise implant location by preoperative
planning. As the planning process matures
with CT-generated applications and tem-
plates, incisions will be needed less often.
After the implant locations are identi-
fied, the first drill in the implant drilling
sequence is used. If available a surgical
stent is placed in order to correctly locate
the implants in relation to the teeth. For
Class III mandibles the implants can be
angled slightly lingually, for Class II
mandibles the implants can be angled
slightly anteriorly, and for Class I
mandibles the implants are placed verti-
cally in relation to the inferior border of
the mandible. Regardless of the angulation
of the implants, the crestal location of the
implants is the same, with the implants
exiting the crest midcrestally without
excessive labial or lingual location.
Augmentation of the
Atrophic Mandible
If the patient is in satisfactory health for a
bone graft harvest procedure, the indica-
tion for bone augmentation of the anteri-
or mandible is a patient with less than
6 mm of bone height. Patients with greater
than 6 mm of bone height can do well
with implants without bone augmenta-
tion.^' Most clinicians wiU use iliac crest
corticocancellous blocks to augment the
height in an atrophic mandible. The pro-
cedure can be performed through either
an intraoral or an extraoral incision,
depending on clinician preference {Figure
10-5). The placement of implants at
the time of bone graft placement is also
196 Part 2: Dentoalveolar Surgery
FIGURE 10-5 A, Iliac crest corticocancellous
block graft augmentation of the atrophic
mandible, through an extraoral approach with
simultaneous placement of two implants. B,
Panoramic radiograph of final prosthesis retained
by two overdenture attachments. Reproduced
with permission from Block MS. Color atlas of
dental implant surgery. Philadelphia (PA): W.B.
Saunders Company, 2001. p. 28.
clinician dependent. If implants are placed
at the time of bone graft placement, then
the patient's time to restoration is
decreased, the graft can be secured to the
mandible with threaded implants, and the
shorter time to functional loading may pre-
vent graft resorption. The disadvantages of
placing implants at the time of bone graft
placement include possible partial resorp-
tion of the graft and exposed portions of
the implants, which is difficult to treat, mal-
position of the implants due to lack of
proper angulation at placement, which can
be technically challenging fVom an extrao-
ral approach, and potential lack of integra-
tion secondary to poor graft remodeling.
Technically the graft procedures are similar,
with the exception of the surgical prepara-
tion of the sites for the implants.
Intraoral incisions for placement of
blocks of bone can be made either crestal-
ly or within the vestibule. The crestal inci- ral approach to graft the atrophic
sion places the incision over the bone mandible include avoidance of intraoral
graft, but it also allows the surgeon to have incision breakdown, avoidance of an
the best chance to avoid incisional dehis- intraoral communication with the bone
cence secondary to vascular insufficiency. graft and potential infection, maintenance
A vestibular incision places the incision of the vestibular attachments, which may
away from the bone graft; however, blood eliminate the need for vestibuloplasty, and
supply to the edge of the vestibular inci- ease of reflection of the inferior alveolar
sion travels through the dense fibrous tis- nerve from the alveolar crest without
sue over the crest and thus may be prone incising over the nerve (Eigure 10-6).
to breakdown secondary to vascular insuf- These advantages often are significant and
ficiency. Both of the intraoral incisions offer the patient the least chance of inci-
and their subsequent release will result in sional dehiscence; hence, this approach is
obliteration of the vestibule, which will the method of choice for these authors.
require secondary soft tissue grafting. One Erom this approach bone grafts can be
should note that the mental foramen is placed in either block or particulate form,
often palpable on the alveolar crest, with with implants used as "tent poles" to
some portion ofthe inferior alveolar nerve maintain space over the graft.^^
dehisced from the mandible secondary to
Most clinicians will allow at least
resorption of the alveolar crest bone.
4 months to healing of the iliac crest cor-
The bone grafts are harvested and ticocancellous bone graft prior to placing
trimmed as necessary. The goal ofthe graft implants. Iliac crest corticocancellous
should be to restore the mandible to
approximately 15 mm of vertical height;
however, for a 3 mm mandible, gaining
this amount of bone may be excessive. Eor
the extremely small 1 to 5 mm tall
mandible, restoring the mandible to 10 to
13 mm is considered a great success. Two
or three pieces of corticocancellous bone
blocks are trimmed and placed over the
superior aspect ofthe mandible. The edges
are smoothed and the grafts are stabilized
in position with screws placed through the
grafts, engaging the inferior border of the
mandible. If implants are placed at the
time of graft placement, the clinician must
weigh the possibility of partial graft
resorption and subsequent implant fail-
ure. Implants can be placed 4 months after
the graft was performed, and combined
with a simultaneous vestibuloplasty.
The disadvantage of using an extraoral
approach is the scar that results and diffi- FIGURE 10-6 A, Atrophic mandible in a
culty placing implants at the time of graft 75'year-old female. B, A 5-year follow-up radi-
placement. Most implants, when placed ograph of 10 mm long implants placed without
bone graft. Reproduced with permission from
into a bone graft performed through an Block MS. Color atlas of dental implant surgery.
extraoral incision, are flared to the labial Philadelphia (PA): W.B. Saunders Company,
aspect. The advantages of using an extrao- 200 L p. 29-30.

grafts heal well but start resorhing after
3 to 4 months, so the surgeon may need to
place the implants at 3 months, depending
on consolidation and remodeling of the
bone graft, which is determined radi-
ographically. If necessary a split- thickness
dissection can be made intraorally and a
palatal or split-thickness dermis or skin
graft can be placed to restore some sem-
blance of vestibule. At the time of vestibu-
loplasty, rigid fixation screws can be
removed and implants placed, engaging
the inferior border of the mandible. When
simultaneously performing a vestibulo-
plasty with implant placement, one should
countersink the implants below the level
of the periosteum so that the graft can lay
flush and not be tented up off the host tis-
sue bed by the dome-like prominence of
the cover screws of implants.
Placement of Implants into
Atrophic Mandibles without
Grafting
The majority of patients with atrophic
mandible with less than 10 mm of bone
height and at least 5 to 6 mm of height are
not good candidates for bone grafting sec-
ondary to health-related issues. For these
patients four implants can be placed, with
1 to 2 mm of the implant through the infe-
rior border of the mandible, and 1 to 2 mm
supracrestal as necessary. It is important to
gently prepare the bone with new sharp
drills and pretap these bones since they can
be brittle and have minimal blood supply.
The implants should be placed to avoid
labial protrusion (see Figure 10-6).'''
Options for the
Edentulous Maxilla
Treatment planning for the edentulous
maxilla is usually initiated at the restorative
dentist's office. This includes establishment
of the patient's goals of what he/she desires
at the completion of implant therapy. Once
these goals are established the surgeon is
seen and an assessment of bone availability
is performed.
Osseointegration 197
A panoramic radiograph and a physi- Parel's classification of the edentulous
cal examination are often all that are maxilla is useful for conceptualization of
required to delineate satisfactory bone the prosthetic plan (personal communica-
bulk for the placement of implants into tion, 1991). The Class I maxilla involves the
the maxilla. From the panoramic radi- patient who seems to be missing only the
ograph one can estimate the amount of maxillary teeth, but has retained the alveo-
vertical bone available throughout the lar bone almost to its original level (Figure
entire maxilla. Occasionally a reformatted 10-7). The Class II maxilla has lost the
CT scan is obtained to confirm the pres- teeth and some of the alveolar bone, and
ence of bone prior to implant placement. the Class III maxilla has lost the teeth and
If cross-sectional radiography is planned, most of the alveolar bone to the basal level.
using a radiopaque stent at the time of the For the Class I patient a fixed restora-
radiography significantly increases the tion, borne by implants, can be fabricated
amount of information gathered. The because the patient has adequate alveolar
teeth in the patient's prosthesis are made bone for support of the soft tissues and is
radiopaque by using a radiopaque mater- missing only the teeth. There is usually
ial, typically 20 to 30% barium sulfate greater than 10 mm of bone height in
combined with clear acrylic so that the both the anterior and posterior maxilla.
teeth are included in the cross-sectional For a fixed crown-and-bridge restoration,
image. This provides information con- implants need to be placed within the
cerning the relationship of the bone to the confines of the teeth of the planned
desired teeth. restoration. The implants should be
C
FIGURE 10-7 A, Edentulous Class 1 maxilla treatment planned for fixed crown-and-bridge maxillary
prosthesis. Reproduced with permission from Block MS. Color atlas of dental implant surgery.
Philadelphia: W.B. Saunders Company, 2001. p. 65. B, Final anterior dentition demonstrating excel-
lent gingival contours on implants in the endentulous maxillary patient. Reproduced with permission
from Block MS. Color atlas of dental implant surgery. Philadelphia (PA): W.B. Saunders Company,
2001. p. 66. C, Milled bar for implant-retained fixed/removable prosthesis. D, fixed/removable pros-
thesis retained by "swing-lock" attachments to the milled bar. Reproduced with permission from Block
MS. Color atlas of dental implant surgery. Philadelphia (PA): W.B. Saunders Company, 2001. p. 19.
198 Part 2: Dentoalveolar Surgery
placed to avoid the embrasure regions in
order to promote esthetics and oral
hygiene. For a fixed crown-and-bridge
restoration, the implants should be placed
3 mm apical to the gingival margin of the
planned restoration in order to allow the
restorative dentist to develop a natural
emergence of the crowns from the gingi-
va. If the Class I patient desires a tissue-
borne overdenture on four implants
because of financial constraints, then the
design of the overdenture bar must be
such as to avoid excessive space-occupy-
ing designs, since the patient is missing
only their teeth, not the alveolus.
The Class II patients rarely can be
esthetically managed with a fixed crown-
and-bridge prosthesis since they require
the labial flange of the maxillary prosthe-
sis to support the nasal-labial soft tissues.
In order to distinguish the need for
acrylic to support the soft tissues, it is
useful to duplicate their maxillary den-
tures and remove the labial flange, leaving
only the teeth. The resultant soft tissue
profile with the modified duplicated
maxillary denture will easily help the
implant team and patient decide on a
treatment plan. If the patients look good
without the fiange of their denture, indi-
cating sufficient nasal-labial support, a
fixed crown-and-bridge restoration can
be fabricated using pink porcelain or
acrylic to decrease apical gaps from lost
alveolar bone. In addition the deficiency
of alveolar bone necessitates placing the
implants more apical than is ideal, result-
ing in excessively long teeth, teeth with
pink acrylic, a removable lip "plumper,"
or a hybrid-type prosthesis with space
between the prosthesis and the implants.
A fixed crown-and-bridge, fixed/
removable (spark erosion or milled pros-
thesis), or removable overdenture-type
prosthesis may be prescribed. The implant-
borne fixed and fixed-removable prostheses
require at least six, or preferably eight,
endosseous implants to adequately support
a maxillary implant-borne prosthesis. The
exception is the use of the Zygomaticus
implant fixtures. These prostheses require
posterior maxillary vertical height of bone
for implants placed in the first molar
region. The removable prosthesis requires
two to four implants placed into the anteri-
or maxilla to support a bar that has reten-
tive vertical stress-breaking attachments.
Edentulous maxillary prostheses are usual-
ly fabricated with cross-arch stabilization of
the left and right implants. Cross-arch sta-
bilization significantly increases implant
survival long term.
Placement of Four Implants
into the Anterior Maxilla
For the patient with adequate anterior ver-
tical bone height, and for whom a treat-
ment plan has been made for anterior
implants for overdenture support, four
implants can be placed. It is recommended
to place at least four implants for a tissue-
supported overdenture in the maxiUa. Four
implants in the anterior maxilla are used to
support a rigid bar, often combined with
vertical stress-broken attachments placed
at the distal aspects. Implants for overden-
tures are typically placed with their centers
slightly palatal to the crest to avoid dehis-
cence and thin bone over the facial aspect
of the implants. The incisive canal should
be avoided as a site for implant placement.
Specifically, implants for overdentures are
place in the canine and premolar locations,
dependent on the availability of bone. An
implant can be placed in the lateral incisor
position if necessary. However, implants
placed in the central incisor locations com-
plicate the prosthetic rehabilitation since
the presence of the abutments and a bar
near the midline may result in excessive
palatal bulk in the denture, which may be
bothersome to the patient.
Placement of Eight Implants
without a Graft
If the goals of the patients are to have a den-
ture or prosthesis that will enable them to
have a palateless prosthesis and allow them
to chew all textured foods without the pros-
thesis dependuig on the tissues for support,
then a sufficient number of implants is
required to resist the forces of mastication.
For these patients it is recommended to use
six to eight implants for an implant-
supported fixed orfixed/removableprosthe-
sis, with an adequate number of implants
located posteriorly to support the molars.
Eight implants in the anterior and
posterior maxilla are used to support a
suprastructure for a totally implant-
borne restoration with tissue contact only
for speech. If a bar-type structure is
planned, the implants should be placed
within the confines of the borders of the
planned prosthesis, and not labial or out-
side the borders of the teeth. The
implants should be placed to avoid
impingement of the teeth in the overden-
ture and to allow space for the fabrication
of the bar. For many of these implant-
borne cases, implants are placed from the
canine region extending posteriorly, with
a minimal number of implants placed
into the incisal region. This pattern of
placement makes the design of the anteri-
or portion of the prosthesis easier.
The implants for fixed/re movable
overdentures are typically placed with
their centers slightly palatal to the crest in
order to avoid dehiscence and thin bone
over the facial aspect of the implants. The
implants can be positioned from second
molar to central incisor; however, most
restorative dentists prefer to avoid of the
central incisor and second molar sites. The
second molar site can be used in select
cases, but it does make the placement of
screws, abutments, and transfer copings
difficult. In addition the bars may need the
space of the second molar site for attach-
ments, depending on the prosthetic design
of the retentive bar.
Placement of Eight Implants
with Sinus Grafts
Patients who have received a treatment plan
or an implant-borne restoration but who
 Osseointegration 199

have insufficient vertical bone for the place-
ment of implants in the maxilla posterior to
the canines are considered for a combina-
tion of sinus grafting and implant place-
ment. The sinus grafts can be performed as
one surgery, followed 6 to 12 months later
with implant placement, or the sinus graft
can be performed and the implants placed
at the time of the sinus graft. If the sinus
graft is performed prior to implant place-
ment, the surgeon should verify that bone
has formed within the graft.
We and our colleagues perform sinus
grafting with immediate placement of
implants. Currently, the recommended
sinus graft material is autogenous bone,
harvested fi-om the jaws, tibia, or iliac
crest. If necessary the autogenous bone
volume can be augmented with deminer-
alized bone in a ratio not to exceed 1:1.
Hydroxylapatite-coated implants are used
for immediate placement into sinus grafts.
ical loading that the restoration and
hence implants will feel. Canine guid-
ance or group function is usually present
and can affect the position of the
implants. Canine discursion is recom-
mended when placing posterior implants
for fixed restorations. The ideal single
premolar or molar restoration has a bal-
anced occlusion that will result in atrau-
matic forces upon the implant. Single-
tooth implants should be placed such
that the implant is under the working
cusp of the tooth, to avoid excessive can-
tilever forces. Maximal length implants
should be used whenever possible. Short
implants in the posterior jaws tend to
have less long-term survival than longer
implants. The crown-to-root ratio needs
to be addressed. Complete treatment
planning, which includes knowledge of
the final restoration, will increase success
and limit complications.
The surgical incision is made slightly
palatal to the crest, with vertical releasing
incisions flaring into the vestibule in order
to keep the base of the flap wider than the
crestal incision width. FuU-thickness sub-
periosteal labial and palatal flaps are reflect-
ed to expose the crest and to provide visu-
alization of the vertical cortices of bone.
The implant should be placed with its axis
parallel to the occlusal forces, with the
emergence of the implant angling to meet
the buccal cusps of the mandibular teeth.
Multiple Implant-Borne
Restorations for the Posterior
Maxilla
Since these restorations commonly
involve the distal teeth, assessment of the
availability of bone in relation to the
sinus is critical. If 10 mm of bone is not
available, then a sinus augmentation is
indicated. If two long implants can be

Single- and Multiple-Unit

Restorations
There are different surgical concerns when
placing single- or multiunit restorations in
the anterior maxilla or other areas where
esthetics are less of a concern. Placement
of implants into premolar and molar loca-
tions can usually be performed with less
concerns of papilla and root eminence
morphology (Figure 10-8).

Premolar or Molar Restorations

Diagnosis and treatment planning will
indicate whether there is sufficient space
and bone available for implant placement.
Periapical radiographs are necessary for
single-tooth restorations to confirm that
the roots of the adjacent teeth do not
impinge in the space that will be used by
the implant. If root angulation is a prob-
lem, then preoperative orthodontics will
need to be performed prior to implant FIGURE 10-8 A, This patient required a single implant for replacement of a premolar in the maxil-
placement, or a fixed bridge can be made la. A tissue punch was used to access the crestal bone. The implant site was prepared and the implant
placed through this circular sofr tissue hole, This implant has an internal connection. B, A fixed abut-
rather than placement of an implant.
ment was placed immediately into the implant and prepared. A provisional crown, not in occlusion,
Careful attention should be directed was fabricated. C, This is the frnal crown. Note the excellent sofr tissue reaction to the crown, abut-
to the final restorations and the mechan- ment, implant complex.
200 Part 2: Dentoalveolar Surgery
placed without the need for a sinus graft,
along with sinus elevation of a third site
by the use of osteotomes, then 8 mm of
bone for the third implant is acceptable.
However, the use of osteotomes to elevate
the sinus floor by 2 mm is not a proce-
dure that has abundant scientific valida-
tion. Therefore the patient must be
apprised of the risks and potential failure.
When in doubt a sinus elevation is per-
formed. The mechanics of the final
restoration need to be taken into consid-
eration when placing multiple implants
for a full quadrant restoration.
There are patients who have suffi-
cient vertical bone but are deficient in
the width projection of the bone. After
maxillary teeth are extracted for a variety
of reasons, facial bone resorption can
occur, leaving the palatal bone intact,
with the alveolus thin and deficient. Plac-
ing the implant in the ideal position may
result in facial bone dehiscence. For the
thin ridge in the posterior maxilla, with
sufficient bone height, several surgical
options are available. These include the
use of particulate bone grafting with
membrane coverage, the use of onlay
bone grafts harvested from the symph-
ysis or ramus, and ridge expansion using
osteotomes or osteotomies.
Restorative Options for
Single-Unit Restorations in the
Anterior Maxilla
Esthetic implant restorations represent a
challenge to reproduce normal-appearing
restorations with normal-appearing soft
tissue profile and integrity. Most implant
sites that require esthetics have deficien-
cies in the ideal bone and overlying soft
tissue, and must be enhanced with a vari-
ety of surgical techniques. A tooth may be
missing because of lack of tooth develop-
ment, caries, external or internal resorp-
tion of teeth following trauma, root canal
complications, bone loss from periodontal
disease, or recent dentoalveolar trauma.
Each of these etiologies has secondary
effects on the proposed implant site. It is
common to find a deficiency in labial bone
with loss of the previous root eminence
form of the ridge. In addition, the overly-
ing soft tissue at the level of the alveolar
crest may be thin, resulting in a lack of
stippling, variations in gingival color, and
increased translucency resulting in parts of
the implant and abutment showing
through the gingiva.
Tbe majority of anterior maxillary
single-tooth sites present with inadequate
bone and soft tissue, requiring both bone
and soft tissue augmentation. The height
of the papilla refiects the underlying cre-
stal bone height on the adjacent teeth.-^^
Careful assessment of the bone levels on
the adjacent teeth enables the surgeon and
restorative dentist to inform patients of
the realistic expectations of retaining or
creating papilla for an esthetic single-
tooth restoration.
The presurgical assessment, using the
esthetic tooth wax-up, results in the ability
of the surgeon to estimate the height and
width of a bone graft, if one is indicated.
For severe bone deficiency, which prevents
implant stabilization, a bone graft should
be placed at least 4 months prior to
implant placement, allowing future
implant placement in the ideal location
horizontally and vertically. When the
deficit of the bone is such that the implant
can be placed and is mechanically stable,
with a portion of its surface exposed
through the bone, then a hard tissue par-
ticulate graft is placed at the same time as
the placement of the implant. The materi-
al used for grafting depends on the extent
of the implant bone fenestration. Autoge-
nous bone is used for larger fenestrations,
with a gradual increase in hydroxylapatite
used as the implant bone dehiscence
decreases in size.
Incision Considerations for
Esthetic Sites
When placing an implant in the central
incisor location, careful attention to the
detail of gaining access to the underlying
bone is critical for obtaining a perfect
result, without ablation of the papilla or
vertical scars from poor incision design
and technique. If there is 5 mm fVom the
contact point of the teeth to the crestal
bone of the adjacent tooth, then the use of
sulcular incisions is indicated. If there are
papillae present but the teeth are long,
with an excess of 5 mm between the con-
tact point to the crestal bone of tbe adja-
cent tooth, then the patient needs to be
warned that papillae may not be present
after implant placement. When necessary,
vertical incisions should be beveled to
allow for esthetic scar healing. When the
bone anatomy permits, the use of a tissue
punch and avoidance of incisions will
allow for no scars and no loss of papilla.
Angulation of the implant should
result in the axis of the implant being ori-
ented to emerge slightly palatal to the inci-
sive edge of tbe planned restoration. If
placed at or anterior to the incisive edge of
the tooth, there may be difficulty in devel-
oping the emergence profile of the restora-
tion. If the implant is placed too far labial,
with the anterior edge of the implant at the
edge of the gingival margin of the planned
tooth, then with addition of the abutment
and porcelain, the gingival contour will be
excessive and gingival recession results. As
the platform {ie, diameter of the implant)
increases, the clinician must be cautious to
ensure that the labial edge of the implant is
not excessively labial, or emergence of the
crown will be compromised and will result
in an obese crown form. Most restorations
require more than I mm of clearance from
the labial surface of the implant to the
eventual clinical crown, secondary to
development of the emergence profile of
the restoration from the subgingival por-
tion of the implant restoration.
The depth of the implant in relation to
the planned gingival margin is also critical.
If the implant is placed too shallow, with
2 mm or less from the top of the implant to
the gingival margin, then several adverse

events can occur. The metal from the
implant may be visible through the gingival
margin. Because the distance ft-om the top
of the implant to the gingival margin is
minimal, metal showing through the gingi-
va is difficult to camouflage. A minimal dis-
tance between the gingival margin and the
top of the implant may also result in diffi-
culty in adjusting the margins of the abut-
ment, with porcelain extending to the
implant itself. It is then difficult to develop a
natural appearance since the gingival mar-
gin region of the restoration is excessively
bulked or round in shape. The use of ceram-
ic abutments may help in these adverse situ-
ations. However, proper implant placement
is a simple means to avoid these problems.
Immediate Loading and
One-Stage Protocol
The evolution of implant-related therapies
in the modern era was based on the work
of Branemark and colleagues, who scien-
tifically validated the process of placing an
implant into bone, waiting a period of
time for bone to heal to the implant, fol-
lowed by long-term functional loading.^^
During the 1970s and early 1980s a one-
stage threaded titanium plasma-coated
implant was used for overdenture reten-
tion with immediate loading. The "Swiss
screw" was placed into the anterior
mandible and had excellent long-term
success. Other one-stage implant systems
were slow to develop, but as they have
emerged with data to support a one-stage
process (ie, with no need for exposure
surgery), the concept of a one-stage
Table 10-1 Options When Extraom^nterl^^axil
Procedure Adjunctive Treatments
Extract tooth No graft; wait 8 wk
Extract tooth Immediate placement of implant
Extract tooth Graft extraction site; wait 4 mo
for implant placement
endosseous implant therapy has gained
credibility. The Strauman system has long-
term data indicating that a one-stage
unloaded implant system can work in all
areas of the mouth, in distinction to the
Swiss screw and the Branemark proto-
cols.''' Recently, more interest has arisen
for placement of implants into the esthet-
ic zone ofthe maxilla, with either immedi-
ate loading or the use of a healing abut-
ment that mimics the natural shape ofthe
tooth. The hypothesis is that by placing a
healing abutment with natural contours,
the soft tissue response will be enhanced,
potentially resulting in a more esthetic
final restoration.
Treatment planning for a one-stage or
immediately temporized anterior maxil-
lary restoration begins with a list of con-
traindications. If a tooth is present and
needs to be extracted, a one-stage exposed
implant placement at the time of extrac-
tion will require the following:
No purulent drainage or exudate from
the site
Excellent gingival tissue quality with-
out excessive granulation tissue
Lack of periapical, uncontrolled radi-
olucency
Adequate bone levels circumferential-
ly without the need for additional soft
or hard tissue grafting
The clinician has several options (Table
10-1). At the time of tooth extraction, if
there are any of the contraindications pre-
sent as described above, either a graft can be
placed into the extraction socket, or no
Advantage
Short time to implant placement
Less time for overall treatment
Provides ideal placement site
Osseointegration 201
graft is placed. The decision to avoid a graft
is based on the thickness of the labial bone
and the prior healing patterns of the
patient, if known. However, in our institu-
tion, an anterior extraction site without a
socket graft is more prone to labial bone
resorption and hence less-than-ideal bone
is available at the time of implant place-
ment. If a graft is placed into the socket,
then after 3 to 6 months, depending on the
material placed, the implant can usually be
placed in an ideal location.
If there is ideal bone and soft tissue
present at the time of extraction, an
implant can be placed at the time of extrac-
tion. The clinician should decide prior to
extraction if a provisional restoration is to
be placed at the time of implant placement,
or if the implant is to have a healing abut-
ment placed for a one-stage protocol, or
submerged for a two-stage protocol.
Preoperative planning for immediate
temporization after implant placement
involves fabrication of a surgical guide
that precisely locates the implant in one
position. The surgeon must work closely
with the restorative dentist to ensure that
the planned placement ofthe implant will
indeed be able to be performed. The
restorative dentist should be available dur-
ing surgery to guide the surgical place-
ment and be able to adapt the temporary
restoration after implant placement.
After the implant is placed and the ori-
entation approved by the restorative den-
tist, the abutment is placed, and removed
as necessary so that changes in its height
and contours can be accomplished outside
1
Disadvantage
—^
Labial bone loss and need for adjunctive
tissue grafts
Increased chance for infection; may not have
ideal bone support upon placement
Extended time for treatment
202 Part 2: Dentoalveolar Surgery
of the mouth. The abutment and tempo-
rary crown may be prepared on a model
prior to surgery in selected cases. The abut-
ment is placed and tightened to the
implant and the temporary crown com-
pleted. The occlusion should be relieved to
avoid loading the implant during the heal-
ing period. In some patients who may be
prone to loading the implant because of
athletics, weight hfting, or their occlusion,
an anatomic healing abutment or a custom
healing abutment can be placed in order to
preserve the morphology of the gingiva,
without the presence of a tooth form.
Procedures performed during the inte-
gration or healing period are delayed until
implant integration has occurred, in order
to avoid disturbance of this critical aspect
of implant success. Approximately
2 months after the implants have been
placed, the patients are seen by the restora-
tive dentist and surgeon to decide, based
on the esthetic set-up, whether the implant
site requires additional augmentation of
the ridge. The goal is to achieve a convex
ridge profile and develop the site's shape to
aUow for the restoration to emerge from
the gingiva, similar to a natural tooth. Our
experience indicates that 70% of the
implant sites that required hard tissue
grafts also benefited from subepithelial
connective tissue grafts placed 3'A months
after implant placement.
Summary
The successful restoration of the patient
with dental implants can result in a change
in dental function and health, with a happy
patient. The basis for the use of dental
implants is initiated by the normal
sequence of wound healing, the translation
of surface engineering to implant design,
and evidence-based trials that verify^ and
confirm efficacy of treatment methods.
References
1. Lemons J, Natiella J. Biomaterials, biocompati-
bility and peri-implant considerations.
Dent Clin North Am 1986;30:3-23.
2. Shulman LB. Transplantation and replantation
of teeth. Laskin: Oral and maxillofacial
surgery. Vol 2. St. Louis (MO): C.V. Mosby
Co.; 1985. p. 132-6.
3. Driskell TD. History of implants. I Calif Dent
Assoc 1987:15:16-25.
4. Bonwell, AC. First District Dental Society. In:
Greenfield EG, editor. Implantation of arti-
ficial bridge abutments. Dent Cosmos
19I3;55:364.
5. Greenfield EJ. Implantation of artificial crown
and bridge abutments. Dent Cosmos
I913;55:364.
6. Harris SM. An artificial tooth. Dent Cosmos
1887;55:433.
7. Adams PB, inventor. Anchoring means for false
teeth. US patent 2,112,007. 1938 March 22.
8. Strock EA. Experimental v/ork on a method for
the replacement of missing teeth by direct
implantation of a metal support into the
alveolus. Am J Orthodont Oral Surg
1939;25:457-72.
9. Dahl GSA. Om impijlighenten for implanta-
tion i Keken au metal iskelett som has eller
rention for fastoc eller avatagbara prostesor.
I Odontol Tidskr 1943;51:440.
10. Linkow Ll. The blade-vent: a new dimension in
endosseous implants. Dent Concepts
1968;! 1:3-12.
11. Roberts HD, Roberts RA. The ramus
endosseous implants. I South Calif Dent
Assocl970;38:571-"7.
12. Proceedings of tbe Toronto Consensus Devel-
opment Conference on Dental Implants. J
Prosthet Dent 1983;49:50.
13. BrSnemark PL Introduction to osseointegra-
tion. In: Branemark PI, et al, editors. Tissue
integrated prostheses. Chicago (IL): Quin-
tessence Publishing Co. Inc.; 1985. p. 29.
14. Schenk RK, Buser D. Osseointegration: a reali-
ty. Periodontology. 2000;17:22-35.
15. SykarasN,Iacopino A, Marker V,et al. Implant
materials, design and surface topographies:
their effect on osseointegration [review].
Int J Oral Maxillofac Implants 2000;
15:675-90.
16. Buser D, Schenk RK, Steinemann S, et al. Influ-
ence of surface characteristics on bone inte-
gration of titanium implants. A histometric
study in miniature pigs. I Biomed Mater
Res 1991;25:889-902.
17. Tbomas KA, Kay JF, Cook SD, Jarcho M. The
effect of surface macrotexture and
hydroxylapatite coating on tbe mechanical
strengths and histologic profiles of titanium
implant materials. J Biomed Mater Res
18. Brunski |B, Puleo DA, Nanci A. Biomateriais
and biomecbanics of oral and maxillofacial
implants: current status and fiature devel-
opments. Int J Oral Maxillofac Implants.
2000:15:15-46.
19. Gordioli G, Zajzoub Z, Piatelli A, ScaranoA.
Removal torque and histomorphometric
study of four difterent titanium surfaces. Int
J Oral Maxillofac Implants 2000; 15:668-74.
20. Cochran DL, Buser D, ten Bruggenkate C, et al
The use of reduced healing times on ITI
implants with a sandblasted and acid-
etched (SLA) surface: early results firom
clinical trials on ITI SLA implants. Clin
Oral Implants Res 2002;l3:144-53.
21. Eriksson RA, Albrektsson T. Temperature
threshold levels for heat-induced bone tis-
sue injury: a vital-microscopic study in the
rabbit. I Prosthet Dent 1983;50:10I.
22. Eriksson RA, Adell R. Temperatures during
drilling for placement of implants using the
osseointegration technique. J Oral Maxillo-
facSurgl986;44:4-7.
23. Watanabe F, Tawanda Y, Komatsu S, Hata Y.
Heat distribution in bone during prepara-
tion of implant sites: beat analysis by real-
time thermograpby. Int J Oral Maxillofac
Implants 1992;7:212-9.
24. Adell R, Lekholm U, Br3nemark PI. Surgical
procedures. In: BrSnemark PI, Zarb GA,
Albrektsson T, editors. Tissue integrated
prostbcses: osseointegration in clinical den-
tistry. Chicago (IL): Quintessence Publish-
ing Co. Inc.; 1985. p. 211-32.
25. Lazzara R, Porter S, Testori T, et al. A prospec-
tive multicenter evaluation loading of
Osseotite implants two months after place-
ment: one-year results. J Estbet Dent
1998;10(6):280-9.
26. Testori T. DelEabbroCH, Feldman S, et al. A
multicenter prospective evaluation of 2-
montbs loaded Osseotite implants placed
in tbe posterior jaws: 3 year follow-up
results. Clin Oral Implants Res 200l;12:l-7.
27. Cooper L, Felton D, Kugelberg C, et al. A mul-
ticenter 12 month evaluation of single-
tooth implants restored 3 weeks after 1
stage surgery. Int J Oral Maxillofac
Implants 2001;]6:182-92.
28. Cooper LF, Scurria MS, Lang LA, et al. Treat-
ment of edentulism using Astra Tech
implants and ball abutments to retain
mandibuiar overdentures. Int J Oral Max-
illofac Implants 1999;14:646-53.
29. Lazzara RJ. Estbetic and restorative benefits of
non-axillary loaded implants. Implant
Dent 1995;4:282-3.
30. Krekeler G, Schilli W, Diemer J. Should the exit
of the artificial abutment tooth be posi-
tioned in the region on attached gingival?
Int J Oral Surg 1985; 14:504-8.

31. Block MS, Kent JN. Factors associated with soft
and hard tissue compromise of endosseous
implants. I Oral Maxillofac Surg 1990;
48:1153-60.
32. Feinberg SE, Steinberg B, Helman J. Healing of
traumatic injuries, In: Fonseca RJ, Walker
RV. Betts Ni, Barber HD, editors. Oral and
maxillofacial trauma. Vol 1. 2nd Ed.
Philadelphia (PA): WB Saunders Co.; 1997.
p. 13-59.
33. Shetty V, Bertolami CN. The physiology of
wound healing. In: Peterson LJ, Indresano
AT, Marciani RD, Roser SM, editors. Prin-
ciples of oral and maxillofacial surgery.
Philadelphia (PA): JB Lippincott; 1992.
p. 3-18.
34. Black J. Reaction of biological molecules with
biomechanical surfaces. In: Black ), editor.
Biologic performance of materials. Funda-
mentals of biocompatibility. New York
(NY): Marcel Dekker; 1981. p. 45.
35. Adell R. A 15 year study of osseointegrated
implants in the treatment of the edentulous
jaw. Int I Oral Surg 1981;10:387-416.
Osseointegration 203
36. Cooper LF. Biologic determinants of bone for-
mation for osseointegration: clues for
future clinical improvements. J Prosthet
Dent 199S;80:439^9.
37. Higuchi KW, Block MS. Current trends in
implant reconstruction. ] Oral Maxillofac
Surg !995;Suppl 1:7-19.
38. Marx RE, Shellenberger T, Winsatt J, Correra P.
Severely resorbed mandible: predictable
reconstruction with soft tissue matrix
expansion (Tent Pole) grafts. I Oral Max-
illofac Surg 2002:60:878-88.