IMPLANTOLOGY IN

DENTAL
TECHNOLOGY(DNT 512)
DENTAL TECHNOLOGY

COMPILED BY
COURSE LECTURER
 IMPLANTOLOGY FOR DENTAL TECHNOLOGY
Implant is a medical device manufactured to replace a missing biological structure,
support or damaged biological structure or enhance an existing biological structure.
It is a man-made device which is inserted into human body for a purpose. It can
also be inform of micro-chip implanted into human body through injection into the
subcutaneous which usually contains a unique ID number that can be linked to
information containing data base for usage like address book, crypto currency
wallet, and key-card and so on.
However, dental (Endosseous implants/fixture) are prosthetic that interfaces with
the bone of the jaw to support a dental prosthesis or to act as an orthodontic
anchor. Therefore, implantology in dentistry is a branch of medicine and dentistry
that focuses on the use of dental implant for teeth/tooth restoration. It is also the
branch of dentistry that focuses on the use of dental implants for teeth/tooth
restorations. Implantology is becoming increasingly widespread and it is taught
worldwide in all dentistry schools. So far, millions of osseointegrated implants
have been inserted in the mouths of patients who were missing one or more of their
natural teeth.
Implant itself is an artificial tooth root inserted into the jawbone to which the
abutment will be fitted. The natural tooth has two main components; the crown and
root whereas, the dental implant has three components; the artificial tooth root, the
abutment and the crown.

Fig i: illustration of natural tooth and dental implnt prosthesis

The basis for modern dental implants is a biological process called

osseointegration in which materials such as titanium or zirconia form an intimate
bond to bone. Therefore, it is imperative to note that, implant fixture is first placed
so that it will likely to osseointegrate, then a dental prosthetic is added. Though a
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variable amount of healing time is required for osseointegration before either the
dental prosthetic (a tooth/bridge or denture) is attached to the implant or an
abutment is placed, which will hold a dental prosthesis/crown.
HISTORICAL BACKGROUND OF IMPLANTOLOGY
It was during the 1950s that Swedish Professor; Per-Ingvar Brånemark discovered
the biocompatibility of titanium with the human body. Prior to the modern dental
implant, dental prostheses had been developed and implemented with varying
degrees of success. Evidence suggests that the use of dental devices goes back to
the days of the ancient Egyptians in 2500 B.C., when gold ligature wire was
perhaps used to stabilize teeth. Around 300 A.D., Phoenicians began crafting
dental implants out of ivory, while Mayans began implanting shells as teeth around
600 A.D. From the 1500s to the 1800s, dentists in Europe would replace teeth with
those collected from cadavers or the poor. Through the earlier parts of the 20th
century, implants which utilized orthopedic screws were being used in dental
procedures.
The discovery that finds Brånemark’s invention being honored by the hall of fame
is that of osseointegration, or the integration of an implant directly into a living
bone and secured in place by the formation of bony tissue around the implant.
Osseointegration can occur using certain ceramic or metal materials and is the
foundation of almost all modern day dental implants as well as other areas of
reconstructive surgery.
As is often the case with scientific discoveries, the discovery of osseointegration
was an unintended consequence of an experiment meant to study a completely
different phenomenon. In the early 1950s, Brånemark was conducting research into
the activity of blood flow in rabbits which involved affixing a titanium implant
chamber to a rabbit’s bone; although it was Brånemark’s intention to later remove
the implant chamber from the rabbit. When he tried to do so, however, he found
that the bony tissue surrounding the implant had integrated with the titanium and
made it impossible for the unit to be removed from the bone. Although he had set
out to discover how blood flow aids in bone healing, he realized that he may have
found a way to create dental implants that could be tolerated by the human body
for years.
This was a discovery that was tough for the medical world to accept for quite some
time. His dental implant was not approved by the National Board of Health and
Welfare in Sweden until the 1970s, two decades after Brånemark’s first scientific
revelations in the field. It was a widely held belief among the upper echelons of the
medical field that any foreign material implanted into the human body would cause
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inflammation leading to rejection of that implant. For his part, Brånemark tried to
assuage the judgment of medical scientists by placing titanium implants in about
20 student volunteers to conduct safety testing. However, the course of time would
prove the Swedish physician to be correct and many have noted how the implants
of Brånemark’s first patient, who received implants in September 1965, survived
until that patient died about forty years later.
It was about forty years after the discovery of osseointegration when Brånemark
was issued U.S. Patent No. 4988299, entitled Implant Fixture for Tooth Prosthesis.
Although Brånemark focused heavily on the impacts that osseointegration would
have in the field of dental implants, the larger medical world has been developing
ever more applications for the bone implant technique, including lower limb
prosthesis that snaps onto a post which has been implanted onto a leg bone using
osseointegration techniques. This system has been pioneered by Dr. Rickard
Brånemark, Per-Ingvar’s son who developed this particular technology at the
University of Gothenburg in Sweden. The use of osseointegration instead of cup
implants also reduces the swelling, sweating and other negative impacts caused by
keeping a large area of the body tightly covered to use prosthesis.
Per-Ingvar Brånemark did not live to see his induction into the National Inventors
Hall of Fame; he passed away in December 2014 at the age of 85. He did,
however, live to see his invention implantation system, which was originally so
widely derided, become a standard medical procedure. He also received honors
from the medical and engineering fields in his lifetime, earning a medal in
technological innovation from the Swedish Engineering Academy and a European
Inventor Award for Lifetime Achievement from the European Patent Office in
2011.

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While studying bone cells in a rabbit tibia using a titanium chamber, Branemark
was unable to remove it from bone. His realization that bone would adhere to
titanium led to the concept of osseointegration and the development of modern
dental implants. The original x-ray film of the chamber embedded in the rabbit
tibia is shown (made available by Branemark).
BIOCOMPATIBILITY AND IMPLANTS
Biocompatibility is a key concept in understanding the host response to implants
and biomaterials. It is also essential to developing medical implants and improving
the performance of those implants.
It is basically the ability of implant materials to function in vivo without eliciting
detrimental local or systemic response in the body. Prior to their use in human
fracture fixation, biomaterials undergo tissue and animal testing to determine their
safety and efficacy. Biomaterials that elicit little or no host response can be thought
of as inert materials. The importance of biocompatibility is demonstrated by the
consequences of allergic reaction, toxicity, irritation and carcinogenic properties.
Therefore the biological rejection of an implant leads to an inflammatory response
mediated by immune cells and can necessitate removal of the implant to avoid
unnecessary complications.
COMPONENT PARTS OF A DENTAL IMPLANT ASSEMBLY
A dental implant alone does not replace a natural tooth. An abutment must be
mounted on the implant once the latter has been inserted into the jawbone.
Depending on the number of teeth to be replaced, an artificial crown, a full or
partial denture or a bridge will be prepared and installed on the abutments.

Fig ii: A dental implant with a crown attached used for a single tooth replacement

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DESIGN AND TYPES OF DENTAL IMPLANTS
1. Endosteal/endosseeous Dental Implants:
Endosteal implants are fused straight into the jaw bone providing an alternative to
permanent denture or bridges. It comes in shape of cylinder which consists of two
screw and abutment. The cylinder may have smooth surface or blade constructed
with titanium, polymeric or ceramics. It uses two stage treatment options.
2. Subperiosteal Dental implants (Eposteal implant):
This type of implant is placed directly on top the jawbone and the metal post is
exposed to hold the restoration. It is most often used in the single stage treatment
option.
3. Transosteal Implants:
This type of implant is the least – used of all types of implants as it is most
complex. One reason is that it involves placing a metal plate to the jawbone’s
underside. Screws are then drilled through the jawbones to secure the plate.
Because of this, transosteal implants can only replace missing lower teeth.
However, they may be the only option for patients who have severe bone
resorption. They may not have enough bone to support an endosteal or
subperiosteal implants.
MATERIALS USED AS DENTAL IMPLANTS
Titanium: The concept of implant rejection, a complication that used to occur
when implants were made of materials that could not be osseointegrated (e.g.: steel
and tantalum), has disappeared with the advent of titanium (a biocompatible
material). It has a good record of being used successfully as an implant material
and this success with titanium implant is credited to its excellent biocompatibility
due to the formation of stable oxide layer on its surface. Though it has a
disadvantage of aesthetic issues due to its grey colour and this is more pronounced
when the soft tissue situation is not optimal and the dark colour shines through the
thin mucosa.
Ceramics: were used for surgical implants devices because of their inert behavior
and good strength and physical properties such as minimum thermal and electrical
conductivity. Although properties like low ductility and brittleness has limited its
usage.

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Zirconia: is an ideal material for dental implants. It’s bio-inert which means that it
will never trigger chemical reactions, migrate to other sites in the body or corrode.
That’s why it’s non-metal alternative to titanium. Its naturally white colour also
makes it a great choice for patients.
Titanium zirconia alloy: it’s with 13-17% zirconia have better mechanical
attributes, such as increased elongation and the fatigue strength that pure titanium.
Note also, that growth of osteoblast that is essential for osseointegration is not
prevented by titanium and zirconia.
TERMINOLOGIES USED IN DENTAL IMPLANTOLOGY
Osseointegration: this is the direct structural and functional connection between
living bone and the surface of a load bearing artificial implant.
Osteoblast: this is a large cell responsible for the synthesis and mineralization of
bone during bone initial formation and later bone remodeling.
Implant: medical device manufactured to replace a missing biological structure or
enhance the damaged biological structure.
Transplant: medical procedure in which an organ or part of human body is
replaced from one body and placed in the body of a recipient.
Abutment: is a connecting element or component. In implant, it is used to attached
crown, bridge or removable denture to the dental implant fixture.
Crown: the visible part of the tooth
Implant fixture: it is the screw-like component that is osseointegrated.
Biocompatibility: this is the ability of a biomaterial to perform its desired function
with respect to a medical therapy without eliciting any effect on the recipient.
Anchorage: this is the way of resisting movement of a tooth or number of teeth by
using different techniques.
Periosteum: an aspect that covers the outer surface of the bone
Endosteum: an aspect that covers the inner surface of the bone

SUCCESS/SURVIVAL RATE
Success or failure of implants depends on the health of the person receiving the
treatment, drugs which affect the chances of osseointegration, and the health of the

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tissues in the mouth. The amount of stress that will be put on the implant and
fixture during normal function is also evaluated. Planning the position and number
of implants is important to the long-term health of the prosthetic since
biomechanical forces created during chewing can be significant. The position of
implants is determined by the position and angle of adjacent teeth, by lab
simulations or by using computed tomography with CAD/CAM simulations and
surgical guides called stents.
The prerequisites for long-term success of osseointegrated dental implants are
healthy bone and gingiva since both can atrophy after tooth extraction, pre-
prosthetic procedures such as sinus lifts or gingival grafts are sometimes required
to recreate ideal bone and gingiva. The final prosthetic can be either fixed, where a
person cannot remove the denture or teeth from their mouth, or removable, where
they can remove the prosthetic. In each case, an abutment is attached to the implant
fixture. Where the prosthetic is fixed, the crown, bridge or denture is fixed to the
abutment either with lag screws or with dental cement. Where the prosthetic is
removable, a corresponding adapter is placed in the prosthetic so that the two
pieces can be secured together. The risks and complications related to implant
therapy divide into:
a. those that occur during surgery (such as excessive bleeding or nerve injury),
b. those that occur in the first six months (such as infection and failure to
osseointegrate) and
c. Those that occur long-term (such as peri-implantitis and mechanical
failures).
In the presence of healthy tissues, a well-integrated implant with appropriate
biomechanical loads can have 5-year plus survival rates from 93 to 98 percent and
10 to 15 year lifespan for the prosthetic teeth. Long-term studies show a 16- to
20-year success (implants surviving without complications or revisions) between
52% and 76%, with complications occurring up to 48% of the time.

MOUTH CONDITIONS CONDUCIVE FOR DENTAL IMPLANT

If one is missing a tooth or teeth, or even parts of the person’s jaw, these could be
replaced with dental implants. First, there are a few very important factors that
must be considered. Experiments and practical experiences have shown that
implants work best when there are enough dense, healthy jawbones in a mouth that
will support an implant.
Healthy, disease-free gum tissues are also necessary. The long-term success of a
dental implant depends upon keeping the gums and bone around the implant
healthy. People who have implants must keep them clean and should return
regularly to their dentist for checkups, because problems that might threaten the

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health of the implant are more easily corrected if remedial measures are initiated in
good time.

TECHNIQUES USED TO PLAN IMPLANTS

To help the surgeon position the implants, a guide is made (usually out of acrylic)
to show the desired position and angulation of the implants. Sometimes the final
position and restoration of the teeth will be simulated on plaster models to help
determine the number and position of implants needed. CT scans can be loaded to
CAD/CAM software to create a simulation of the desired treatment. Virtual
implants are then placed and a stent created on a 3D printer from the data.

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Restoration is simulated on Plaster models to help determine the number and position of implant
s needed.

To help the surgeon position the implants, a guide is made (usually out of acrylic) to show the
desired position and angulations of the implants

Prosthetic Phase
The first step in the prosthetic Phase is to attach the implant abutments. Implant
abutments are artificial devices that are connected to the dental implants after the
healing process and are then used to attach the prosthetics to the implant fixtures.
Abutments come in a wide range of sizes and shapes, from which the ones that best
fit the clinical case are selected. Generally, the selection is done when the

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treatment plan is devised, before the surgical placement (though this is not a
general rule).

The implant and the abutment Abutments of various implant types

After the selection, the abutments are attached to the implant fixtures with a lag-
screw. There are some variations on this, such as when the abutment and implant
body are one piece or when a custom made abutment is used.
Another variation is when the crown and abutment are one piece and the lag-screw
traverses both to secure the one-piece structure to the internal thread on the
implant.
An abutment is not necessarily parallel to the long axis of the implant. Angulated
abutments are utilized when the implant is at a different inclination in relation to
the proposed prosthesis. The main purpose in this case is to make all artificial
abutments parallel to each other.

Impression of the dental arches

The impression is made after the abutments are attached to the implants.
Regardless of the size of the restoration, a complete impression (that captures all
teeth and surrounding structures) of both dental arches is taken.

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Complete impression for an implant supported denture

It is advisable to use the custom tray technique or, if the prosthesis is not very
extended, the two step technique. When removable dentures are designed, a
functional impression is needed.
In some variations, after the impression, the abutment is unscrewed from the
implant and sent to the dental laboratory along with the impressions.

Detached abutment

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Bite registration
The bite registration captures the relationship between the upper and the lower
teeth. The long-term success of implants is determined, in part, by the forces they
have to support. Therefore, restoring a proper occlusion (or bite) is one of the most
important goals.
It is essential not to overload the implants with additional pressures and to evenly
distribute the chewing forces of the implants. Otherwise, there is a high risk of
failure.
Many times the usual techniques do not provide enough data for the dental
technologist. In complex situations, it is advisable to use advanced jaw tracking
devices that provide additional details.

Jaw tracking device

The jaw tracking devices provide details about the precise position of the maxilla
and mandible against different anatomical structures of the head. This information
is extremely useful when manufacturing large restorations that need to be
extremely accurate.
Dental laboratory stages
All the impressions, along with the bite registration and other important details are
sent to the dental laboratory. The dental technologist will fabricate the designed
prosthesis according to the specifications received from the dental clinic.
Laboratory stages are largely the same as in other prosthetic phases :
 first, the dental cast is obtained from the impression

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 The metal framework (or zirconia) is constructed. This follows the usual
procedures of wax pattern buildup, investment, wax elimination (burnout) and
finally casting. After which the recovered metallic framework is trimmed,
polished, finished and sent to the dental clinic for trial fitting.
 the next operation is the ceramics build up and the attachment of artificial teeth
(if a removable denture was designed)
 When all porcelain or zirconia restorations are designed, these are constructed
with the CAD/CAM technology.

Fitting
Before the restoration is definitively attached to the dental implants, one or more
fitting appointments may be needed. During these appointments, the practitioner
checks how well the prosthesis fits and makes the necessary adjustments if the
fitting is not perfect.
The dentist will first check the fitting of the framework, then, after porcelain build
up, the shape, size and general appearance of the prosthesis are tested.

Procedures for removable dentures

Overdentures:
A cast bar of metal is secured to the implants. The complete denture then attaches
to the bar with semi-precision attachments allowing no movement of the denture.
Ball and socket type attachments can be placed on implants and dentures to prevent
most movement. When a removable denture is worn, retainers to hold the denture
in place can be either custom made or "off-the-shelf" (stock) abutments. When
custom retainers are used, four or more implant fixtures are placed and an
impression of the implants is taken and a dental laboratory creates a custom metal
bar with attachments to hold the denture in place. Significant retention can be
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created with multiple attachments and the use of semi-precision attachments (such
as a small diameter pin that pushes through the denture and into the bar) which
allows for little or no movement in the denture, but it remains removable.
However, the same four implants angled in such a way to distribute occlusal forces
may be able to safely hold a fixed denture in place with comparable costs and
number of procedures giving the denture wearer a fixed solution. Alternatively,
stock abutments are used to retain dentures using a male-adapter attached to the
implant and a female adapter in the denture. Two common types of adapters are the
ball-and-socket style retainer and the button-style adapter. These types of stock
abutments allow movement of the denture, but enough retention to improve the
quality of life for denture wearers, compared to conventional dentures. Regardless
of the type of adapter, the female portion of the adapter that is housed in the
denture will require periodic replacement; however the number and adapter type
does not seem to affect patient satisfaction with the prosthetic for various
removable alternatives.

General considerations:
Planning for dental implants focuses on the general health condition of the patient,
the local health condition of the mucous membranes and the jaws and the shape,
size, and position of the bones of the jaws, adjacent and opposing teeth. There are
few health conditions that absolutely preclude placing implants. There are certain
conditions that can increase the risk of failure, for instance: Those with poor oral
hygiene, heavy smokers and diabetics are all at greater risk for a variant of gum
disease that affects implants called peri-implantitis, increasing the chance of long-
term failures. Long-term steroid use, osteoporosis and other diseases that affect the
bones can increase the risk of early failure of implants. The use of bone building
drugs, like bisphosphonates and anti-RANKL drugs require special consideration
with implants, because they have been associated with a disorder called
Bisphosphonate-associated osteonecrosis of the jaw (BRONJ). The drugs change
bone turnover, which is thought to put people at risk for death of bone when
having minor oral surgery. At routine doses (for example, those used to treat
routine osteoporosis) the effects of the drugs linger for months or years but the risk
appears to be very low. Because of this duality, uncertainty exists in the dental
community about how to best manage the risk of BRONJ when placing implants.

Biomechanical considerations:
The long-term success of implants is determined, in part, by the forces they have to
support. As implants have no periodontal ligament, there is no sensation of
pressure when biting so the forces created are higher. To offset this, the location of
implants must distribute forces evenly across the prosthetics they support.
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Concentrated forces can result in fracture of the bridgework, implant components,
or loss of bone adjacent the implant. So:
i. The ultimate location of implants is based on both biologic (bone type,
vital structures, health) and mechanical factors.
ii. Implants placed in thicker, stronger bone like that found in the anterior
part of the lower jaw have lower failure rates than implants placed in
lower density bone, such as the posterior part of the upper jaw.
iii. People who grind their teeth also increase the force on implants and
increase the likelihood of failures. The design of implants has to account
for a lifetime of real-world use in a person's mouth.

Basic implant surgical procedure

For an area with a single missing tooth, an incision is made across the gingiva, and
the flap of tissue is reflected to show the bone of the jaw. Once the bone is
exposed, a series of drills create and gradually enlarge a site (called an osteotomy)
for the implant to be placed. The implant fixture is turned into the osteotomy.
Ideally, it is completely covered by bone and has no movement within the bone. A
healing abutment is attached to the implant fixture, and the flap of gingiva is
sutured around the healing abutment.

Placing the implant

Most implant systems have five basic steps for placement of each implant. a). Soft
tissue reflection: An incision is made over the crest of bone, splitting the thicker
attached gingiva roughly in half so that the final implant will have a thick band of
tissue around it. The edges of tissue, each referred to as a flap are pushed back to
expose the bone. Flapless surgery is an alternate technique, where a small punch of
tissue (the diameter of the implant) is removed for implant placement rather than
rising flaps. b). Drilling at high speed: After reflecting the soft tissue, and using a
surgical guide or stent as necessary, pilot holes are placed with precision drills at
highly regulated speed to prevent burning or pressure necrosis of the bone. c).
Drilling at low speed: The pilot hole is expanded by using progressively wider
drills (typically between three and seven successive drilling steps, depending on
implant width and length). Care is taken not to damage the osteoblast or bone cells
by overheating. A cooling saline or water spray keeps the temperature low.
d). Placement of the implant: The implant screw is placed and can be self-
tapping; otherwise the prepared site is tapped with an implant analog. It is then
screwed into place with a torque controlled wrench at a precise torque so as not to
overload the surrounding bone (overloaded bone can die, a condition called
osteonecrosis, which may lead to failure of the implant to fully integrate or bond
with the jawbone).
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e). Tissue adaptation: The gingiva is adapted around the entire implant to provide
a thick band of healthy tissue around the healing abutment. In contrast, an
implant can be "buried", where the top of the implant is sealed with a cover screw
and the tissue is closed to completely cover it. A second procedure would then be
required to uncover the implant at a later date.

Timing of implants after extraction of teeth

There are different approaches to placement of dental implants after tooth
extraction. The approaches are:
1. Immediate post-extraction implant placement.
2. Delayed immediate post-extraction implant placement (two weeks to three
months after extraction).
3. Late implantation (three months or more after tooth extraction).
There are also various options for when to attach teeth to dental implants,
classified into:
1. Immediate loading procedure.
2. Early loading (one week to twelve weeks).
3. Delayed loading (over three months)

Healing time
For an implant to become permanently stable, the body must grow bone to the
surface of the implant (osseointegration). Based on this biologic process, it was
thought that loading an implant during the osseointegration period would result in
movement that would prevent osseointegration, and thus increase implant failure
rates. As a result, three to six months of integrating time (depending on various
factors) was allowed before placing the teeth on implants (restoring them).
However, later research suggests that the initial stability of the implant in bone is a
more important determinant of success of implant integration, rather than a certain
period of healing time. As a result, the time allowed to heal is typically based on
the density of bone the implant is placed in and the number of implants splinted
together, rather than a uniform amount of time. When implants can withstand high
torque (35 Ncm) and are splinted to other implants, there are no meaningful
differences in long-term implant survival or bone loss between implants loaded
immediately, at three months, or at six months. The corollary is that single
implants, even in solid bone, require a period of no-load to minimize the risk of
initial failure.

One versus two-stage surgery

After an implant is placed, the internal components are covered with either a
healing abutment, or a cover screw. A healing abutment passes through the
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mucosa, and the surrounding mucosa is adapted around it. A cover screw is flush
with the surface of the dental implant, and is designed to be completely covered by
mucosa. After an integration period, a second surgery is required to reflect the
mucosa and place a healing abutment. In the early stages of implant development
(1970−1990), implant systems used a two-stage approach, believing that it
improved the odds of initial implant survival. Subsequent research suggests that no
difference in implant survival existed between one-stage and two-stage surgeries,
and the choice of whether or not to "bury" the implant in the first stage of surgery
became a concern of soft tissue (gingiva) management. When tissue is deficient or
mutilated by the loss of teeth, implants are placed and allowed to osseointegrate,
and then the gingiva is surgically moved around the healing abutments. The down-
side of a two-stage technique is the need for additional surgery and compromise of
circulation to the tissue due to repeated surgeries. The choice of one or two-stages
now centers on how best to reconstruct the soft tissues around lost teeth.

Immediate placement
An increasingly common strategy to preserve bone and reduce treatment times
includes the placement of a dental implant into a recent extraction site. On the one
hand, it shortens treatment time and can improve aesthetics because the soft tissue
envelope is preserved. On the other hand, implants may have a slightly higher rate
of initial failure. Conclusions on this topic are difficult to draw, however, because
few studies have compared immediate and delayed implants in a scientifically
rigorous manner.

Additional surgical procedures

Hard tissue reconstruction- If bone width is inadequate it can be regrown using
either artificial or cadevaric bone pieces to act as a scaffold for natural bone to
grow around. When a greater amount of bone is needed, it can be taken from
another site (commonly the back of the bottom jaw) and transplanted to the implant
site. The maxillary sinus can limit the amount of bone height in the back of the
upper jaw. With a "sinus lift", bone can be grafted under the sinus membrane
increasing the height of bone. For an implant to osseointegrate, it needs to be
surrounded by a healthy quantity of bone. In order for it to survive long-term, it
needs to have a thick healthy soft tissue (gingiva) envelope around it. It is common
for either the bone or soft tissue to be so deficient that the surgeon needs to
reconstruct it either before or during implant placement.

Hard tissue (bone) reconstruction

Sinus lift and Bone grafting- Bone grafting is necessary when there is a lack of
bone. While there are always new implant types, such as short implants, and
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techniques to allow compromise, a general treatment goal is to have a minimum of
10 mm in bone height, and 6 mm in width. Alternatively, bone defects are graded
from A to D (A=10+ mm of bone, B=7–9mm, C=4–6mm and D=0–3 mm) where
an implant's likelihood of osseointegrating is related to the grade of bone. To
achieve an adequate width and height of bone, various bone grafting techniques
have been developed. The most frequently used is called Guided bone graft
augmentation where a defect is filled with either natural (harvested or autograft)
bone or allograft (donor bone or synthetic bone substitute), covered with a semi-
permeable membrane and allowed to heal. During the healing phase, natural bone
replaces the graft forming a new bony base for the implant. Three common
procedures are: The sinus lift Lateral alveolar augmentation (increase in the width
of a site) Vertical alveolar augmentation (increase in the height of a site) Other,
more invasive procedures, also exist for larger bone defects including mobilization
of the inferior alveolar nerve to allow placement of a fixture, onlay bone grafting
using the iliac crest or another large source of bone and microvascular bone graft
where the blood supply to the bone is transplanted with the source bone and
reconnected to the local blood supply. The final decision about which bone
grafting technique that is best is based on an assessment of the degree of vertical
and horizontal bone loss that exists, each of which is classified into mild (2–3 mm
loss), moderate (4–6 mm loss) or severe (greater than 6 mm loss). Orthodontic
extrusion or orthodontic implant site development can be used in selected cases for
vertical/horizontal alveolar augmentation.

Soft tissue (gingiva) reconstruction

Gingival graft and Subepithelial connective tissue graft/ Soft tissue reconstruction.
When mucosa is missing, a free gingival graft of soft tissue can be transplanted to
the area. When the metal of an implant becomes visible a connective tissue graft
can be used to improve the mucosal height. The gingiva surrounding a tooth has a
2–3 mm band of bright pink, very strong attached mucosa, then a darker, larger
area of unattached mucosa that fold into the cheeks. When replacing a tooth with
an implant, a band of strong, attached gingiva is needed to keep the implant
healthy in the long-term. This is especially important with implants because the
blood supply is more precarious in the gingiva surrounding an implant, and is
theoretically more susceptible to injury because of a longer attachment to the
implant than on a tooth (a longer biologic width). When an adequate band of
attached tissue is absent, it can be recreated with a soft tissue graft. There are four
methods that can be used to transplant soft tissue. A roll of tissue adjacent to an
implant (referred to as a palatal roll) can be moved towards the lip (buccal),
gingiva from the palate can be transplanted, deeper connective tissue from the
palate can be transplanted or, when a larger piece of tissue is needed, a finger of
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tissue based on a blood vessel in the palate (called a vascularized interpositional
periosteal-connective tissue (VIP-CT) flap) can be repositioned to the area.
Additionally, for an implant to look esthetic, a band of full, plump gingiva is
needed to fill in the space on either side of implant. The most common soft tissue
complication is called a black-triangle, where the papilla (the small triangular piece
of tissue between two teeth) shrinks back and leaves a triangular void between the
implant and the adjacent teeth. Dentists can only expect 2–4 mm of papilla height
over the underlying bone. A black triangle can be expected if the distance between
where the teeth touch and bone is any.

Recovery
The steps taken to secure dental crowns on the implant fixture including placement
of the abutment and crown, the prosthetic phase begins once the implant is well
integrated (or has a reasonable assurance that it will integrate) and an abutment is
in place to bring it through the mucosa. Even in the event of early loading (less
than 3 months), many practitioners will place temporary teeth until
osseointegration is confirmed. The prosthetic phase of restoring an implant
requires an equal amount of technical expertise as the surgical because of the
biomechanical considerations, especially when multiple teeth are to be restored.
The dentist will work to restore the vertical dimension of occlusion, the esthetics of
the smile, and the structural integrity of the teeth to evenly distribute the forces of
the implants.

Maintenance
After placement, implants need to be cleaned (similar to natural teeth) with a
Teflon instrument to remove any plaque. Because of the more precarious blood
supply to the gingiva, care should be taken with dental floss. Implants will lose
bone at a rate similar to natural teeth in the mouth (e.g. if someone suffers from
periodontal disease, an implant can be affected by a similar disorder) but will
otherwise last. The porcelain on crowns should be expected to discolour, fracture
or require repair approximately every ten years, although there is significant
variation in the service life of dental crowns based on the position in the mouth, the
forces being applied from opposing teeth and the restoration material. Where
implants are used to retain a complete denture, depending on the type of
attachment, connections need to be changed or refreshed every one to two years.
Powered irrigator may also be useful for cleaning around implants.

Risks and complications

During surgery: Placement of dental implants is a surgical procedure and carries
the normal risks of surgery including infection, excessive bleeding and necrosis of
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the flap of tissue around the implant. Nearby anatomic structures, such as the
inferior alveolar nerve, the maxillary sinus and blood vessels can also be injured
when the osteotomy is created or the implant placed. Even when the lining of the
maxillary sinus is perforated by an implant, long term sinusitis is rare. An inability
to place the implant in bone to provide stability of the implant (referred to as
primary stability of the implant) increases the risk of failure to osseointegration.
Implant complications Bone loss (peri-implantitis) on implants over 7 years in a
heavy smoker. Recession of the gingiva leads to exposure of the metal abutment
under a dental crown. Black triangles caused by bone loss between implants and
natural teeth Fracture of an implant and abutment screw are a catastrophic failure
and the fixture cannot be salvaged. Fracture of an abutment (all-zirconia) requires
replacement of the abutment and crown. Fracture of abutment screws (arrow) in 3
implants required removal of the remainder of the screw and replacement. Dental
cement under the gingiva causes peri-implantitis and implant failure.

Fracture of abutment screws (arrow) in 3 implants required removal of the remainder of the
screw and replacement.

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Primary implant stability
Primary implant stability refers to the stability of a dental implant immediately
after implantation. The stability of the titanium screw implant in the patient's bone
tissue post-surgery may be non-invasively assessed using resonance frequency
analysis. Sufficient initial stability may allow immediate loading with prosthetic
reconstruction, though early loading poses a higher risk of implant failure than
conventional loading. The relevance of primary implant stability decreases
gradually with regrowth of bone tissue around the implant in the first weeks after
surgery, leading to secondary stability. Secondary stability is different from the
initial stabilization, because it results from the ongoing process of bone regrowth
into the implant (osseointegration). When this healing process is complete, the
initial mechanical stability becomes biological stability. Primary stability is critical
to implantation success until bone re-growth maximizes mechanical and biological
support of the implant. Re-growth usually occurs during the 3–4 weeks after
implantation. Insufficient primary stability, or high initial implant mobility, can
lead to failure.

Immediate post-operative risks

Infection (pre-op antibiotics reduce the risk of implant failure by 33 percent but do
not affect the risk of infection). Excessive bleeding Flap breakdown (less-than 5
percent)

Failure to integrate
An implant is tested between 8 and 24 weeks to determine if it is integrated. There
is significant variation in the criteria used to determine implant success, the most
commonly cited criteria at the implant level are the absence of pain, mobility,
infection, gingival bleeding, radiographic lucency or peri-implant bone loss not
greater than 1.5 mm. Dental implant success is related to operator skill, quality and
quantity of the bone available at the site, and the patient's oral hygiene, but the
most important factor is primary implant stability. While there is significant
variation in the rate that implants fail to integrate (due to individual risk factors),
the approximate values are 1 to 6 percent. Integration failure is rare, particularly if
a dentist's or oral surgeon's instructions are followed closely by the patient.
Immediate loading implants may have a higher rate of failure, potentially due to
being loaded immediately after trauma or extraction, but the difference with proper
care and maintenance is well within statistical variance for this type of procedure.
More often, osseointegration failure occurs when a patient is either too unhealthy
to receive the implant or engages in behavior that contraindicates proper dental
hygiene including smoking or drug use.

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Long term
The long-term complications that result from restoring teeth with implants relate,
directly, to the risk factors of the patient and the technology. There are the risks
associated with appearance including a high smile line, poor gingival quality and
missing papillae, difficulty in matching the form of natural teeth that may have
unequal points of contact or uncommon shapes, bone that is missing, atrophied or
otherwise shaped in an unsuitable manner, unrealistic expectations of the patient or
poor oral hygiene. The risks can be related to biomechanical factors, where the
geometry of the implants does not support the teeth in the same way the natural
teeth did such as when there are cantilevered extensions, fewer implants than
roots or teeth that are longer than the implants that support them (a poor crown-to-
root ratio). Similarly, grinding of the teeth, lack of bone or low diameter implants
increase the biomechanical risk.

Technological risks are where the implants themselves can fail due to fracture or a
loss of retention to the teeth they are intended to support. From these theoretical
risks, derive the real world complications. Long-term failures are due to either
loss of bone around the tooth and/or gingiva due to peri-implantitis or a mechanical
failure of the implant. Because there is no dental enamel on an implant, it does not
fail due to cavities like natural teeth. While large-scale, long-term studies are
scarce, several systematic reviews estimate the long-term (five to ten years)
survival of dental implants at 93–98 percent depending on their clinical use.
During initial development of implant retained teeth, all crowns were attached to
the teeth with screws, but more recent advancements have allowed placement of
crowns on the abutments with dental cement (akin to placing a crown on a tooth).
This has created the potential for cement that escapes from under the crown during
cementation to get caught in the gingiva and create a peri-implantitis. While the
complication can occur, there does not appear to be any additional peri-implantitis
in cement-retained crowns compared to screw-retained crowns overall. In
compound implants (two stage implants), between the actual implant and the
superstructure (abutment) are gaps and cavities into which bacteria can penetrate
from the oral cavity. Later these bacteria will return into the adjacent tissue and can
cause periimplantitis. As prophylaxis these implant interior spaces should be
sealed.

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Dental cement under the gingiva causes peri-implantitis and implant failure.

Criteria for the success of the implant supported dental prosthetic varies from study
to study, but can be broadly classified into failures due to:
1. the implant,
2. soft tissues,
3. prosthetic components or
4. A lack of satisfaction on the part of the patient.
The most commonly cited criteria for success are function of at least five years in
the absence of pain, mobility, radiographic lucency and peri-implant bone loss of
greater than 1.5 mm on the implant, the lack of suppuration or bleeding in the
soft tissues and occurrence of technical complications/prosthetic maintenance,
adequate function, and esthetics in the prosthetic. In addition, the patient should
ideally be free from pain, paraesthesia, able to chew and taste and be pleased with
the esthetics.

JOINT TREATMENT PLANNING

The next phase in the treatment planning process involves the entire implant team
including the surgeon (if separate), prosthodontist, and other specialists. The
hygienist or laboratory technologist may also be included. The planning
conferences provide opportunities for the team to review the patient's chief

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complaints, expectations, history, and current medical and dental status. Based on
all this information, team members can formulate a detailed treatment plan.

USES OF DENTAL IMPLANT

The primary use of dental implants is to support dental prosthetics. Modern dental
implants make use of osseointegration, the biologic process where bone fuses
tightly to the surface of specific materials such as titanium and some ceramics. The
integration of implant and bone can support physical loads for decades without
failure. Implants are therefore used in the following situations:
1. For individual tooth replacement, an implant abutment is first secured to the
implant with an abutment screw. A crown (the dental prosthesis) is then
connected to the abutment with dental cement, a small screw, or fused with the
abutment as one piece during fabrication.

2. Dental implants, in the same way, can also be used to retain a multiple tooth
dental prosthesis either in the form of a fixed bridge or removable dentures. An
implant supported bridge (or fixed denture) is a group of teeth secured to
dental implants so the prosthetic cannot be removed by the user. Bridges
typically connect to more than one implant and may also connect to teeth as
anchor points. Usually the number of teeth will outnumber the anchor points
with the teeth that are directly over the implants referred to as abutments and
those between abutments referred to as pontics. Implant supported bridges
attach to implant abutments in the same way as a single tooth implant
replacement. A fixed bridge may replace as few as two teeth (also known as a
fixed partial denture) and may extend to replace an entire arch of teeth (also
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 known as a fixed full denture). In both cases, the prosthesis is said to be fixed
because it cannot be removed by the denture wearer,

3. A removable implant supported denture (also an implant supported

overdenture is a type of dental prosthesis which is not permanently fixed in
place. The dental prosthesis can be disconnected from the implant abutments
with finger pressure by the wearer. To enable this, the abutment is shaped as a
small connector (a button, ball, bar or magnet) which can be connected to
analogous adapters in the underside of the dental prosthesis.

Implant supported overdenture

4. Facial prosthetics, used to correct facial deformities (e.g. from cancer treatmen
t or injuries) can utilize connections to implants placed in the facial bones. Dep
ending on the situation the implant may be used to retain either a fixed or remo
vable prosthetic that replaces part of the face.

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5. In orthodontics, small diameter dental implants, referred to as Temporary
Anchorage Devices (TADs) can assist tooth movement by creating anchor
points from which forces can be generated. For teeth to move, a force must be
applied to them in the direction of the desired movement.
The force stimulates cells in the periodontal ligament to cause bone
remodeling, removing bone in the direction of travel of the tooth and adding
it to the space created. In order to generate a force on a tooth, an anchor point
(something that will not move) is needed. Since implants do not have a
periodontal ligament, and bone remodeling will not be stimulated when tension
is applied, they are ideal anchor points in orthodontics. Typically, implants
designed for orthodontic movement are small and do not fully osseointegrate,
allowing easy removal following completion of treatment.

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6. When Augmenting broken tooth root, dental implant copings can be used to
form part of the lost root and a prosthetic crown is used to form a part of or the
entire crown.

THE BENEFITS OF DENTAL IMPLANTS

Dental implants are a highly effective way to replace teeth that are damaged,
decayed, or otherwise can't be repaired through a filling or a crown with a strong,
natural-looking replacement.

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Dental implants come with a variety of benefits, making them an excellent option
for many patients:
i. Replace Multiple Teeth: With dental implants, we can replace one tooth,
multiple teeth, or an entire dental arch.
Natural Looking: Modern dental implants are designed to perfectly mirror the look
and feel of natural teeth, and we can color match your implants to fit in perfectly
with the rest of your mouth. After the implant has had time to fully set in, your
implant will look indistinguishable from your other teeth.
ii. Fuses to Jawbone: One of the main advantages of implants is that unlike
dentures, they literally fuse with your jawbone. This is because the implant
inserted into your jaw is made from titanium, which has the unique property of
osseointegration: bone will grow into and fuse with the metal. Osseointegration
makes dental implants feel just as strong as natural teeth, allowing you to eat,
speak, and smile with total confidence.
iii. Durability: When cared for properly, your dental implants will last you a
lifetime. Because the implants fuse into your natural jawbone, they provide a
permanent solution instead of a temporary fix. The fact that they last so long makes
them one of the best-value treatments we offer – after the initial setup procedure,
your implant will last a lifetime.
iv. Protects Your Bones: With other treatments like dentures, there's often a
danger of bone loss from eating. This is because dentures are attached to the
jawline by an adhesive, which means that they put pressure on the jawbone when
eating or biting down. Over time, this pressure wears out the jaw and causes bone
loss. With implants, however, the pressure is distributed evenly throughout the jaw
because the implants are a part of the jaw – just like with natural teeth. This means
that implants prevent bone loss, healthfully distributing pressure from biting and
protecting your mouth for years to come.
v. No Effect on Natural Teeth: While some other treatments may weaken or
stress adjacent teeth, dental implants have no effect on surrounding teeth at all.
This means you can have your tooth replaced with an implant while keeping the
healthy teeth around it, protecting the health of your natural smile.

vi. Same Care as Natural Teeth: With dental implants, you don't need to do
anything special to maintain the health of your mouth – just maintain your regular
oral hygiene regimen of daily brushing and flossing. The implants feel just like

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natural teeth, and you'll never have to deal with special creams or cleaning
practices to maintain them. Once the implants have fully set in and fused into your
jaw, they're almost identical to natural teeth in every way.
Side effects of dental implants
i. Risks of Infection at the implant site.
ii. Injury or damage to surrounding structures, such as other teeth or blood
vessels.
iii. Nerve damage, which can cause pain, numbness or tingling the natural
teeth, gums, lips or chin.
iv. Sinus problems, when dental implants placed in the upper jaw protrude
into one of the sinus cavities.

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