IMPLANTS

The Future of Prosthodontics

Kalpa Pandya
Rachayta Parikh
Priyank Pareek

(Final B.D.S.)
 What is an Implant???

A prosthetic device or alloplastic material implanted into the oral tissue

beneath the mucosal or/and periosteal layer and/ or in the bone to
provide retention and support for the fixed and removable prosthesis.
- GPT
 History
• 936 – 1013 First documented placement of implants
Albucasis de Condue– used ox bone to replace teeth

• 1809 Maggiolo - Gold roots which were fixed with adjacent teeth by
means of spring

• 1887 Platinum post coated with lead

• 1895 Gold or iridium tubes were implanted – Bonewell

• 1905 Porcelain corrugated root implant

• 1913 Hollow basket implant meshwork or iridium , platinum , gold

- Greenfield

• 1948 Insertion of first viable subperiosteal implant – Goldberg

• 1952 Threaded implant design of pure titanium

Endosteal implants - Branemark
Single/multiple missing tooth/Teeth

What are the treatment options available ???????

 Single/multiple missing tooth/Teeth
1. Removable Partial Denture (R.P.D.)

2.Fixed Partial Denture (F.P.D.)

?
3. Implant Prosthesis
 Removable Partial Denture
(R.P.D.)
DISADVANTAGES :-
1. do not maintain bone
- compromise the
esthetic result

2. bulk – need for

cross arch stabilization

3. food debris , plaque

4. movement
-speech
-function

5. highest loss of abutment teeth

 Fixed partial denture
(F.P.D.)
DISADVANTAGES :-
1. caries and endodontic
failure of abutment teeth is the
most common failure

2. increased plaque retention of pontic increases caries

and periodontal disease risk

3. damage to healthy teeth

4. fracture ( porcelain , tooth )

5. esthetics ( anterior region )

6. uncemented restorations
 Fixed partial denture
(F.P.D.)…

• It is contra indicated in
1. Poor abutment teeth support

2. inadequate hard and soft tissue in esthetic regions

3. patient desire

4. young patients with large pulp horns

 Implants for
single/multiple tooth
replacement
ADVANTAGES :-
1. Adjacent teeth do not require splinted
restoration
- less risk of caries
- less risk of endodontics
- Less risk of porcelain fracture
- Less risk of uncemented restoration
- Less fracture of tooth
2. Psychological need of patient
3. Improved hygiene conditions
- less decay risk
- less pontic overhang
4. Decreased cold and contact sensitivity
5. Improved esthetics
6. Maintains bone in site
7. Decreases adjacent tooth loss
 Completely Edentulous Patient

Treatment options

Conventional removable dentures Implant supported prosthesis

?
 Decreased performance of conventional complete
dentures

1. Bite force is decreased from 200 psi to 50 psi

2. Masticatory efficiency is decreased
3. More drugs are required to treat gastrointestinal disorders
4. Food selection is limited
5. Healthy food intake is decreased
 Implants for complete dentures
1. maintain bone
2. restore and maintain occlusal vertical
dimension
3. maintain facial esthetics (teeth positioned for
appearance versus
decreasing denture movement )
4. Improve phonetics
5. Improve occlusion
6. Improve / regain oral proprioception
7. Increase prosthesis success
8. Maintains muscle of mastication and facial
expression
9. Reduce size of prosthesis
10. Improve stability and retention of removable
prosthesis
11. More permanent replacement
12. More psychological health
 Indications for implants
• Edentulous patient
• Partially edentulous patient with history of difficulty in wearingR.P.D.
• Patient requiring long span F.P.D.treatment
• Patient who refuses wearing a removable prosthesis
• Patient with severe changes in C.D.bearing tissues
• Poor oral muscular coordination
• Parafunctional habits that compromise prosthesis stability
• Unrealistic patient expectation for complete denture
• Hyperactive gag reflex
• Patient psycologically against removable prosthesis
• Unfavourable number and location of abutments
• Single tooth loss, avoid preparation of sound teeth
ATTACHMENT MECHANICS
 Mechanism Of Integration Of Endosteal Implants

2 concepts were proposed

1. Dr. Branemark concept

concept of osseointegration

2. Weiss concept
concept of fibro – osseous integration
 WEISS THEORY

1. fibro ossseous ligament formed

between implant and the bone
collagen fibers at bone implant
interface

ligament = periodontal ligament

1. early loading of the implant was advocated

• Fibrous connective tissue does not act as shock absorber nor
resemble PDL.
• The non-mineralised connective tissue results from inflammtion
with a tendency to
• proliferate, gradually increasing implant mobility.
 BRANEMARK’S THEORY OF OSSEOINTEGRATION

• Bone is laid very close to the implant

material without an intervening Connective
tissue

• “the apparent direct attachment or

connection of osseous tissue
to an inert alloplastic material without
intervening connective tissue”

- G.P.T.

• IMPLANT should be left out of function

during the healing phase
 The Interface

• Surgical area undergoes a remodelling process just like an extraction site

• If overloading then - implant failure

• Bone grows into the irregularities( macroscopic & microscopic )

of the implant surface

• depending on the reaction with bone :-

1. bioactive ( hydroyapatite )
2. bio – inert ( metals )
 MECHANISM OF OSSEOINTEGRATION

First mechanism
• Integration occurs mainly through osteoconduction

• Connective tissue scaffolding

• Bone-producing cells( osteoblasts ) migrates

Second mechanism
• “de novo” bone formation wherein a mineralized interfacial matrix is
deposited along the implant surface
• Surface topography will determine the bond strength of bone to the
implant surface
5
 Factors Affecting Osseointegration

1. Occlusal load
• - 2 stage implant insertion is advocated
• - overloading prematurely will cause failure
2. Biocompatibility of material
• - commercially pure titanium
• - commercially pure noibium
• - hydroxyapetite

3. Implant design
• - most conducive - cylindrical

4. Implant surface
• - mild surface roughness
 Factors Affecting Osseointegration

5. Surgical site
• healthy site is required

6. Surgical technique
• minimum possible trauma

7. Infection control
CLASSIFICATION OF IMPLANTS
 I) Depending on the placement within the
tissues

• Epithelial implants
• Epiosteal / Subperiosteal implants
• Endosteal implants
• Transosteal implants
 Epithelial implants
• Implant is inserted into the oral mucosa

Disadvantages
• 1. painful healing
• 2. requirement of continual wear
Epiosteal / Subperiosteal Implant
• Receives primary bone support
by resting on it
• Placed directly beneath the
periosteum overliying the bony
cortex

Disadvantages :
1) Slow, predictable rejection of
the implant
2) Bone loss associated with
failure
 Endosteal Implants
Extends into basal bone for support
It transects into 1 cortical plate
 Endosteal implants

Ramus frame implants

Root form implants Plate form implants

-Used over vertical -used over horizontal
column of bone Column of bone
1. Cylinder
2. Screw root form
3. Combination
 Transosteal Implant
• Also called as Staple Bone
Implant, Transmandibular
Implant

• Penetrates both cortical plate

and passes through the entire
thickness of the alveolar bone

• Use restricted to anterior area of

mandible
 II) Depending on the materials used

i) METALLIC IMPLANTS
• titanium
• cobalt chromium molybdenum alloy-
Titanium aluminum vandium
• Cobalt chromium molybdenum
• Stainless steel
• Zirconium
• Tantalum
• Gold
• Platinum
2. NON – METALLIC IMPLANTS
- ceramics
- carbon
 Depending On Their Reaction With Bone

• Based on the ability of implant

to stimulate bone formation
1. Bio active
• Hydroxyapatite
• Tri Calcium Phosphate
• Calcium Phosphate
• 2. Bio inert
metals
 Most commonly used

– Commercially pure (CP) titanium

– Titanium-aluminum-vanadium alloy (Ti-6Al-4V) -
stronger & used with smaller diameter implants
Titanium

•Lightweight
•biocompatible
•corrosion resistant
(dynamic inert oxide layer)
•strong & low-priced
•It is 6 times stronger than compact bone
•Its modulus of elasticity is 5 times greater than that of
compact bone
(thus equal mechanical stress transfer)
PARTS OF AN IMPLANT
 Generic Prosthetic Component Terminology

• Generic language for endosteal implant was developed by

Mish & Mish (1992 )

• The order in which it is presented follows the chronology of

insertion to restoration
 Generic implant body terminology

1. Implant body
ENDOSTEAL IMPLANTS
- root form designed to use vertical column of bone , similar to root of
natural tooth

3 different categories
1. cylinder implants
2. screw design implants
3. combination
Cylinder Implants
-coating or surface condition provide microscopic retention to the bone
hydroxyapatite
titanium plasma spray

- pushed or tapped into prepared bone site

- ease of placement
Screw Design Implants
- slightly smaller prepared bone site
- macroscopic retentive elements

Combination
 Implant Body Regions
3 parts
1. crest module ( cervical geometry )
2. body
3. apex

crest module ( cervical geometry )

body

apex
 Implant Body Regions

Body
- designed for implant bone interface

Crest module

- designed to retain the prosthetic component

- transition zone from implant body design to transosteal region at the

crest of the ridge

- has a platform on which abutment is seated

- when it is a smooth and polished metal – cervical collar

 Prosthetic Attachment
Abutment
portion of the implant that supports or retains a prosthesis
or implant superstructure

Superstructure
metal framework that attaches to the implant abutment
and provides either retention for removable prosthesis
or framework for fixed prosthesis

prosthesis
superstructure

abutment

Implant body
 Categories of implant abutment
based on method by which prosthesis or
superstructure is retained to the abutment

1. Screw retention

2. cement retention

3. for attachment
• attachment device to retain a removable
prosthesis
 Prosthesis fabrication

• Impression is necessary
to transfer the position
and design of implant
or abutment to the
master cast for
prosthesis fabrication

• Transfer coping – used

to position a dye in an
impression
Two types of transfer coping
1. direct transfer coping
2. indirect transfer coping
 Laboratory fabrication
Analog –
• defined as something that is
analogous to something else

• Analog is placed on the transfer coping and

the impression is poured
Prosthetic coping is a thin covering usually designed to fit the
Implant abutment for screw retention

It serves as a connection between abutment and prosthesis or

superstructure
 Implant surgery
Implant system broadly are of 2 types

2. two piece implant system

1. one piece implant system implant system
implant body + prosthodontic prosthodontic abutment
abutment

immediate One stage Two stage

 Implant surgery…
Two stage surgery
1st surgery
- implant body placed below the soft tissue

after initial bone healing has occurred

2nd surgery
-soft tissue are reflected
- permucosal element or abutment is attached
One stage surgery
1st surgery
- implant and permucosal element placed
after initial bone healing has occurred -
abutment replaces the permucosal element without
reflection of flap
 Prosthesis screw

coping

Analog
A)implant body
B) abutment
Transfer coping
A) direct
B) indirect
Hygiene screw

Abutment
A) for screw retentin
B) for cement retention
C) for attachment
Second stage permucosal extension
or healing abutment

First stage cover screw

Implant body
PROSTHETIC OPTIONS IN IMPLANT
DENTISTRY
 Types of prosthesis can be given
• 1. fixed
• 2. removable

FP 1 : Fixed prosthesis
• Replaces only crown
• Looks like natural tooth
Types of prosthesis can be given…

• FP – 2 :
• fixed prosthesis
replaces crown and portion
of root
• hyper-contoured gingival half
 Types of prosthesis can be given…

• FP – 3 : Fixed prosthesis
• Replaces missing crown
,gingival color and portion of
edentulous site
Types of prosthesis can be given…

RP – 4
• Removable prosthesis
Overdenture supported
completely by implant
 Types of prosthesis can be given…

RP – 5 :
• Removable
prosthesis,
overdenture
supported
both by soft
tissue and
implant
 Dental examination

Bone density classification

Dense cortical (D1) bone

• Highest bone implant
contact (BIC) > 80%
• Anterior region of mandible very
dense compact bone
 Dental examination…

• Dense to thick porous

cortical and coarse
trabecular bone (D2)

• BIC = 70%

1. Dense to porous compact

bone on the outside and
coarse trabecular bone on
the inside
2. Anterior and posterior
mandible
 Dental examination…
• Thin porus cortical and fine
trabecular bone (d3)
BIC = 50 %

1. Thinner porous compact bone

and fine trabecular bone

2. Anterior or posterior maxilla

and posterior mandible

3. Implants coated with

hydroxyapatite are indicated
 Dental examination…

• Fine trabecular bone (d4)

BIC = < 25 %

1. No cortical crestal bone

2. posterior maxilla in long term
edentulous patients
CONTRAINDICATIONS
 Absolute Contraindications For Implant
Treatment

• High dose irradiated pt

• Patient with psychiatric problems

• Systemic Hematologic disorders

 Relative Contraindications

• Pathology of hard or soft tissues

• Recent extraction sites

• Patient with drug, alcohol or chewing tobacco

• Low dose irradiated patient

 Posterior Single Tooth Implant

local contraindications for a posterior single indications for a posterior three unit fpd
tooth implant
inadequate bone volume inadequate bone volume
faciopalatal < 5 mm inadequate intertooth space < 6.5 mm
mesiodistal < 6.5 mm lack of intertooth boney height
Moderate to advanced mobility of 2 – 4 Adjacent teeth are mobile
adjacent teeth
Limited time for patient treatment Reduced time of treatment
Limiting Factors For Anterior
Single Tooth Implant
 Age Limitations
• Growth and
development may
be affected by an
implant as it may act
as an ankylosed
tooth.
• As a general rule,
implant insertion is
delayed for female
patient till atleast 15
years and in male
patients until 18 yrs
of age.
 Mesio-distal Space
• A traditional 2 piece implant
Should be atleast 1.5mm from
an adjacent tooth. When the
implant is closer than this, any
bone loss will cause the
implant and the adjacent
tooth to lose bone rapidly.

• This will compromise the inter-

proximal aesthetics and
sulcular health of the implant
and the natural teeth.
 Bone height
• The ideal mid-crestal position of the edentulous site should be 2mm apical
from the facial CEJ of the adjacent teeth.

• When the bone crest is above this, a bone graft procedure may be
performed.

• The inter-proximal
bone should be
scalloped 3mm more
incisal than the
mid-crestal position.
 Challenging Aesthetics

• Cross sections of teeth are not round and are often larger in
facio-palatal dimensions.

• The cervical emergence profile of a crown on a round implant

needs to be created prosthetically.
 Crown Height Space

• The implant abutment will be too short for the

proper retention.
EVIDENCE BASED STUDIES ON
IMPLANT DENTISTRY
Do implant retained or supported dentures improved masticatory
performance???
-Fueki K, Kimoto K, Ogawa T, Garrett NR published in
J Prosthet Dent. 2007 Dec; 98(6):470-7.
Results
• 18 articles met the criteria for inclusion. Experimental studies showed:
1. fixed implant-supported partial dentures do not provide significant
improvement in masticatory performance compared to conventional
removable partial dentures for Kennedy Class I and II partially edentulous
mandibles.
2. the combination of a mandibular implant-supported or retained
overdenture (IOD) and maxillary conventional complete denture (CD)
provides significant improvement in masticatory performance compared
to CDs in both the mandible and maxilla for a limited population having
persistent functional problems with an existing mandibular CD due to
severely resorbed mandible.
 Do implant retained or supported dentures improved
masticatory performance???
-Fueki K, Kimoto K, Ogawa T, Garrett NR.
Results…
3. the type of implant and attachment system for mandibular IODs has a
limited impact.

• Well-designed, experimental studies showed ;

i. mandibular fixed implant-supported complete dentures provide
significant improvement in masticatory performance compared to
mandibular CDs in subjects dissatisfied with their CDs; and

ii. implant-supported mandibular resection dentures have an advantage

over conventional dentures in masticatory performance on the defect side
of the mouth.
 Do implant retained or supported dentures improved
masticatory performance???
-Fueki K, Kimoto K, Ogawa T, Garrett NR…...

Conclusions
• While a number of studies on masticatory performance have
been conducted in patients with various designs of implant-
supported or retained dentures, high-level evidence
supporting advantages in masticatory performance of
implant-supported or retained dentures over conventional
dentures is limited.
 Do implant retained or supported dentures improved
masticatory performance???
-Fueki K, Kimoto K, Ogawa T, Garrett NR…...
• Moreover, two RCTs that compared IOD with new complete dentures
concluded that IOD enhanced the masticatory improvement compared
with conventional complete dentures. This difference reached statistical
significance at 1 year follow-up.

• In conclusion, subjects with low ridge or severe ridge resorption profit

from implant-supported overdentures by increased masticatory
performance and totally edentulous patients profit from fixed implant-
supported complete denture from a masticatory point of view in general.

• Finally, it must be kept in mind that masticatory performance based on the

ability of the subjects to chew hard food is only a part of oral health
related quality of life. Other factors such as, satisfaction with treatment
and oral confidence of the subjects also play a major role.
Recent Advances
 Immediate Function Implants
• Today, modern implant design and the use of 3D CAT Scans allow
experienced dental professionals to insert the implants, and
immediately place the new teeth on the implants. Research has
shown that when properly applied, this one-stage approach results in
as good or better implant success rates as the traditional two-stage
approach.

• Benefits of Immediate Function

● Shortened treatment time (it is possible to go from tooth loss to
having functional
and aesthetic teeth in one treatment session),
● Better clinical efficiency,
● Greater patient comfort,
● The elimination of bone grafts and sinus lifts, and
● Patients always leave with teeth!
 All – on – 4 Implant
• The All-on-4 Dental Implant Procedure uses four implants, with the back
implants angulated to take maximum advantage of existing bone.

• Special implants also were developed that could support the immediate
fitting of replacement teeth.

• This treatment is attractive to those with dentures or in need of full upper

and/or lower restorations.

• With the All-on-4 Procedure, qualified patients receive just four implants
and a full set of new replacement teeth in just one appointment—without
bone grafts!
•All four titanium implants are placed so that the bone will
grow around and secure them in place
•With only four implants, there is much less invasive and
lengthy surgery.
•Once the implants are in place, the Oral Surgeon attaches abutments to which the
new replacement teeth can be secured.

•The Prosthodontist fits the replacement teeth on the abutments and adjusts the
bite for comfort and a beautiful smile
 Interdenatal Esthetics
• A number of cases show deficiency of papilla in the interdental
papilla between the implant or between implants and teeth, which
poses an esthetic problem.

• This is counteracted by injection of hyaluronic acid, commonly

available as Restylane.

• Its effect lasts for 6 – 24 months after which a new dose is

administered.
 Conclusion
• Appropriate case selection, good occlusal harmony, careful
management of hard and soft tissues, and maintainance of oral
hygiene all contribute the success and predictability of dental
implants.
• All health care proffesionals, today are compelled to become
knowledgeable in all aspects of dental implant therapy and
continue their education as new information and evidence becomes
available. Thus implants can truly be regarded as the…
“BRIGHT FUTURE OF PROSTHODONTICS” !!
 References
• Contemporary implant dentistry- Carl Misch
• Osseointegration and occlusal rehabilitation- Sumiya Hobo
• J Prosthet Dent. 2007 Dec; 98(6):470-7.