Basic Surgical Techniques for Endosseous

Implant Placement
WHAT IS A DENTAL IMPLANT?

 Dental implant is an
artificial titanium fixture
which is placed surgically
into the jaw bone to
substitute for a missing
tooth and its root(s).
History of Dental Implants

In 1952, Professor Per-Ingvar Branemark,

a Swedish surgeon, while conducting research
into the healing patterns of bone tissue, accidentally
discovered that when pure titanium comes into
direct contact with the living bone tissue, the two
literally grow together to form a permanent
biological adhesion. He named this phenomenon
"osseointegration".
First Implant Design by Branemark

All current implant

designs are
modifications of this
initial design
Surgical Procedure

STEP 1: INITIAL SURGERY

STEP 2: OSSEOINTEGRATION PERIOD
STEP 3: ABUTMENT CONNECTION
STEP 4: FINAL PROSTHETIC
RESTORATION
Fibro-osseous integration

• Fibroosseous integration
– “tissue to implant contact with dense collagenous
tissue between the implant and bone”
• Seen in earlier implant systems.
• Initially good success rates but extremely
poor long term success.
• Considered a “failure” by todays standards
Osseointegration
• Success Rates >90%
• Histologic definition
– “direct connection between living bone and load-
bearing endosseous implants at the light
microscopic level.”
• 4 factors that influence:
Biocompatible material
Implant adapted to prepared site
Atraumatic surgery
Undisturbed healing phase
Soft-tissue to implant interface
• Successful implants have an
– Unbroken, perimucosal seal between the soft
tissue and the implant abutment surface.
• Connect similarly to natural teeth-some differences.
– Epithelium attaches to surface of titanium much
like a natural tooth through a basal lamina and
the formation of hemidesmosomes.
Soft-tissue to implant interface
• Connection differs at the connective tissue level.
• Natural tooth Sharpies fibers extent from the
bundle bone of the lamina dura and insert into the
cementum of the tooth root surface
• Implant: No Cementum or Fiber insertion.
Hence the Epithelial surface attachment is
IMPORTANT
 INDICATIONS AND CONTRAINDICATIONS :

1. Patients with partially or fully edentulous arches may be considered for dental
implants.

2. Individuals who are unable to wear removable dentures and have adequate
bone for insertion of an implant are good candidates, provided they are in good
general health and are able to maintain good oral hygiene.

3. Uncontrolled diabetes, prolonged steroid therapy, radiation therapy and abuse

of alcohol and smoking may contribute to the failure of the implants.

4. Presence of periodontal disease is also considered to be a contraindication for

dental implant placement.

5. Patients who failed to maintain plaque control are poor candidates for implant
therapy.
 IMPLANT PLACEMENT

• Always design a thing by considering it in its larger

context-a chair in a room ,a room in a house ,a house
in an environment, an environment in a city plan
Team Approach
• A surgical – prosthodontic consultation is done prior
to implant placement to address:
– soft-tissue management
– surgical sequence
– healing time
– need for ridge and soft-tissue augmentation
Clinical Assessment
• Assess the CC and Expectations
• Review all restorative options:
– Risks and Benefits
• Select option that meets functional and esthetic
requirements
 IMPLANT CLASSIFICATION

• DESIGN

• HEX

• STAGE

• PIECE
 Cylindrical
Implant

Conical
Implant
OPTIMIZE THE IMPLANTATION

Dia. 2,7 mm Lenght

5 mm

Dia. 3 mm
 IMPLANT DESIGN

• Thread design

Surface Treatment
 IMPLANT DESIGN

Cylinder
V-shape
Reverse buttress
Square
 THREAD DESIGN

• Each thread design is going to place specific stresses on the

bone. A cylinder will place predominantly shear stresses on
the bone when loaded while a square thread will place
predominantly compressive force. Typically, bone responds
more favorably to compressive force and negatively to shear
stress. The squarethread should be able to withstand more
load. With this in mind one should consider the potential
load and bone type when selecting an implant.
 SURFACE TREATMENT

Machined
Blasted
Etched
Ha
combination
 IMPLANT DESIGN

• Length and width

• Larger implants-greater initial stability
• Wider implants-more load distribution
• Awareness of vital structures
• Utilise good judgments to place the
adequate implant for the site
• Functional surface area:

• “The area that actively serves to dissipate

compressive and non-shear loads through the
implant- bone interface and provide initial stability
of the implant following surgical placement.” –Dr Carl
Misch
Subperiosteal
Transmandibular Implant
Blade Implant
Endosteal Implants
 BONE

 Available bone using the Misch-Judy Classification.

 Type A >5mm width (buccal-lingual dimension), >10mm height

(vertical),>7mm length (mesial ?distal dimension), <30
degrees angulation,and a crown-implant ratio better than 1:1.

 Type B Barely sufficient in 1 or more measurement

 Type Bw Barely sufficient width
 Type Cw Compromised width
 Type Ch Compromised height
 Type D Deficient.
 BONE DENSITY

• Bone Density Classification

• D1 Dense cortical
• Anterior mandible

• D2 Variable thickness cortical bone with course trabecular within.

• Posterior mandible

• D3 Thin cortical bone with fine trabecular within.

Posterior mandible,anterior maxilla

• D4 Fine trabecular bone

• Posterior maxilla

• D5 Immature, non-mineralized bone.

• Recent extraction sites
 Restoration
• Classification

• FP 1
• FP 2
• FP 3
• RP 4
• RP 5
FP 1
FP 2
FP 3
LABORATORY COMMUNICATION
 Long-term success is most dependent on proper
management of formitted to the implant-bone interface.
As long as those forable threshold of the bone, success
can be expected. eliminated, reduced, or balanced are:
 -Magnitude
 -Duration
 -Direction
 -Type
 -Magnification
 Regular monitoring of the implant and restoration is
necessarry
 insure these force factors are kept within range.
STEPS IN IMPLANT RESTORATION
• Pre-Surgical

• Surgical

• Post Surgical
 PRE-SURGICAL

 Patient Evaluation

 Case Selection

 Case Evaluation

 Case-Presentation
 PATIENT EVALUATION

• Psychological

• Medical
Patient Evaluation
• Medical history
– vascular disease
– immunodeficiency
– diabetes mellitus
– tobacco use
– bisphosphonate use
 History of Implant Site

• Factors regarding loss of tooth being replaced

– When?

– How?

– Why?

• Factors that may affect hard and soft tissues:

– Traumatic injuries

– Failed endodontic procedures

– Periodontal disease

• Clinical exam may identify ridge deficiencies

Surgical Phase- Treatment Planning
• Evaluation of Implant Site
• Radiographic Evaluation
• Bone Height, Bone Width and Anatomic
considerations
Basic Principles
• Soft/ hard tissue graft bed
• Existing occlusion/ dentition
• Simultaneous vs. delayed reconstruction
 CASE SELECTION
• Level Of Education

• Expertise

• Armamentarium and Facilities

 Case –Evaluation/Diagnostics

• Models

• Radiographs

• CT Scan
 Models
• Inter-Arch Distance

• Available space Mesio-Distally

• Available Bone-

• Prosthesis Plan
 Radiographs
• IOPA

• OPG

• Implant Overlay
 CAT SCAN

• A fundamental part of implant diagnosis is a good

radiographic study, which will contribute largely to
the surgeons success. For a long time, most of the
dentist had used panoramic and intra oral
radiography, together with positioning guides , as
their main diagnostic tools. Bone width and quality
were estimated based on experience. Treatment
planning was vague & imprecise.
• Software like Implant 3D are user friendly, cost
effective with all the features to make it ready for
use. It is user friendly & does not require any special
software to be loaded to take the CT images.
• It allows the visualization of internal bone
morphology in three dimensions; therefore the
dental surgeon can plan his treatment precisely.

• In cross sectional view, observation regarding bone

quality,density can be made typically by direct
measurement,if they are present in life size format.
 ADVANTAGES
The advantage of CT Scan technology allows for an
accurate assessment of :

a) Bone height & width

b) Identification of soft & hard tissue pathology
c) Location of anatomical structures
d) Measuring the vital qualitative dimensions
necessary for implant placement.
Smile Line
• One of the most influencing factors of any
prosthodontic restoration
• If no gingival shows then the soft tissue quality,
quantity and contours are less important
• Patient counseling on treatment expectations is
critical
Anatomic Considerations
• Ridge relationship
• Attached tissue
• Interarch clearance
• Inferior alveolar nerve
• Maxillary sinus
• Floor of nose
Width of Space and Diameter of Implant

Attention must be paid to both the coronal and

interradicular spaces
A case against routine CT
• Expense
• Time consuming process
• Use of radiographic template/proper fit requires DDS
present
• Contemporary panoramic units have tomographic
capabilities
• Usually adds no additional data over standard
database
Anatomic Limitations

Buccal Plate 0.5mm

Lingual Plate 1.0 mm
Maxillary Sinus 1.0 mm
Nasal Cavity 1.0mm
Incisive canal Avoid
Interimplant distance 1-1.5mm
Inferior alveolar canal 2.0mm
Mental nerve 5mm from foramen
Inferior border 1 mm
Adjacent to natural tooth 0.5mm
 CASE PRESENTATION

• Diagnostic Wax Up

• Case Reports

• Possibilities

• Animation

• Models

• Costing
Dental Implant Surgery Phase I

• Aseptic technique
• Minimal heat generation
– slow sharp drills
– internal irrigation?
– external cooling
Dental Implant Surgery Phase I

• Adequate time for integration

• Adequate recipient site
– soft tissue
– bone
• Kind & Gentle technique
Disposition

1. Chlorhexidine
2. Analgesics
+/- antibiotics
Implant placement 3 months after menton bone
grafting
Exposure of Implant during Placement
Limitations to Implant placement in the
Maxilla

• Ridge width
• Ridge height
• Bone quality
Surgical Solutions to Anatomical Limitations

Onlay Bone Graft Sinus Lift

Stage II Surgery Preoperative Considerations

• Done under local anesthesia

• Pre-op medications
– Chlorhexidine rinse
 Placement of
healing abutment
 conclusions
• The failing implant is very difficult to treat
• Traumatic surgical manipulation with
initial instability of implant increases risk
of failure
• Implant success is only as good as the
prosthodontic reconstruction