DENTAL IMPLANTS

Dr. D.M. Ajayi.

August, 2017.
Outline
• Introduction
• Historic Background
• Types of Dental Implants
• Indications & Contraindications
• Advantages & Disadvantages
• Applications.
• Treatment Planning
• Surgical & Restorative Protocols. ETC
Introduction
• A dental implant is a prosthetic device of alloplastic material
implanted in oral tissues beneath the mucosal or/and periosteal layer
and/or within the bone to provide retention and support for a fixed or
removable prosthesis.
• Simply put, a dental implant is a device inserted into or on the jaw
bone to anchor an artificial tooth or prosthesis.
• It provides a predictable way of restoring function and aesthetics.
• Dental implants are so natural-looking and feeling; you may forget
you ever lost a tooth.
• Dental implants will fuse with bone; however, they lack the
periodontal ligament, so they will feel slightly different than natural
teeth during chewing.
Historic Background
• Pre-osseointegration
• Discovery of Osseointegration
• Post- osseointegration
Pre-osseointegration
• Man attempted to implant carved shells into ant. mandible in 600AD.
• In 1931, the archaeological excavations in Honduras revealed that the
Mayan civilization had the earliest known examples of dental
implants, dating from about 600 AD, when a fragment of mandible
with implants was found.
• However, the first documented dental implant did not appear until
1809, with a poor success rate.
• In 1949,Dr. Norman Goldberg & Dr. Aaron Gershkoff described the
subperiosteal implant framework.
• In 1968, Dr. Small introduced the Transosseus implant.
• In 1966, Dr. Linkow presented “Blade Implant”(now known as an
endosseus implant.)
Discovery of Osseointegration
• This concept was an accidental discovery in 1960’s by Prof. Per-Ingvar
Branemark (A Swedish Orthopaedic Surgeon).

• Implanted titanium chamber in the bone of a rabbit to study wound

healing.

• Discovered that the bone fused to the titanium surface and became
inseparable.
• In 1965, he placed four implants to support a bridge in a patient who
had several congenitally missing teeth.

• Branemark published many studies on the use of Ti implants, and

between 1978 and 1981,he cofounded a company for the
development and marketing of dental implants.
Post –osseointegration
• Branemark system(Cylindrical) was introduced to the USA In 1982.
• Also available are Vented cylinders, expansive screws, and hollow
posts
• Over 100 systems are now available.
• Recent progress in the past century has focused on material and
techniques to improve quality and anchorage.
• The development of modern ceramics started in 1992; and from that
time on, dental implant companies, have incorporated ceramic
surface treatments and ceramic-like elements to enhance
osseointegration.
Types of implant
I. Mucosal Insert

II. Endodontic Implant (Stabilizer)

III. Transosseous implant

IV. Sub-periosteal implant

V. Endosteal or Endosseous implant

I. Titanium mucosal insert
II. Endodontic Implant (Stabilizer)
• Endodontic implants are similar to
Prosthodontic implants in many
respects.

• However, they serve another

purpose—the stabilization and
preservation of remaining natural
teeth, not the replacement of lost
teeth.
III. Transosteal implants
• Placed through the mandible
(only)
• Attachments reside above ridge
• Rarely used now because they
necessitate an extra oral surgical
approach for placement.
 The two attachments

long screw posts

The plate

A typical Transosseous Implant. The plate on the bottom is

firmly pressed against the bottom part of the chin bone,
whereas the long screw posts go through the chin bone, all
the way to the top of the jaw ridge inside the mouth. The two
attachments that will eventually protrude through the gums
can be used to attach an overdenture-type prosthesis.
Dr,salah hegazy
IV. Subperiosteal implant
• rests on alveolar ridge, no bone
invasion

• Less invasive,

• less stable

• Supports denture
V. Endosseous
• 3 types; plate/blade form, ramus
frame and the root form-(Most
common)
• Placed in the bone
• Single tooth or multiple teeth
replacement
• Screwed or non screwed
• Cylindrical or tapered
• Surface treatment
• Grit blasting, plasma sprayed etc
Indications of Dental Implants

• Good general health

• Adequate bone quality and volume
• Appropriate occlusion and jaw relations
• Inability to wear conventional prosthesis
• Unfavourable number/location of abutment
• Single tooth loss
Contraindications
• Suggested absolute contraindications include:
• Recent myocardial infarction and cerebrovascular accident
• Transplant or valvular prosthesis surgery
• Profound immunosuppression
• Severe bleeding issues
• Active treatment of malignancy
• Drug abuse
• Psychiatric illness
• Intravenous bisphosphonate use
Relative Contraindications
• Children and adolescents
• Epileptic patients
• Unrealistic patient expectations
• Alcoholism
• Smoking
• Parafunctional habits
• Psychological factors
• Inadequate ridge/inter-arch dimensions
Relative Contraindications
• Hypothyroidism
• Diabetes
• Coronary artery Disease
• Drug therapy: e.g Anticoagulants
• Osteoporosis
Advantages of Dental implant

• No preparation of adjacent teeth.

• Bone stabilization and maintenance
• Retrievability
• Improvement of function
• Psychological improvement
• May be fixed or removable.
• High level of predictability.
• It can last for a life time.
Disadvantages of Dental Implant.

• Involves elective surgery.

• High operator/technique dependent.
• High initial expense.
• Lengthy treatment time.
• Requires some moderate maintenance.
• Depends on the availability of adequate bone quantity and quality.
• Challenging aesthetic
Applications of Dental Implant
• Replacement of lost tooth teeth due to :
• Trauma,(Avulsed tooth, fractured tooth,etc)
• Dental disease (gross caries, endodontic failures, periodontitis etc)
• or developmental abnormalities(congenitally missing tooth,).
• To overcome problems of free end saddle
• Anchorage for orthodontic tooth
• Single tooth replacement
• Fixed multiple tooth loss- Implant retained bridge prosthesis
• Completely edentulous patients – implant retained removable dentures.
Implant Materials
• An ideal implant material should:
• Be compatible
• Have adequate toughness
• Have high strength
• Resist corrosion, wear and fracture
• Could be made from metals, ceramics or polymers.
I. Metals
• Titanium - Gold standard
• Titanium alloys, SS, Cobalt chromium alloy, Gold alloys, Tantalum.
• Six distinct types of titanium are available that is, four grades of
commercially pure titanium (Cp Ti) and two titanium (C Ti) alloys.
• Cp Ti – Pure grades I, II, III & IV titanium (with different mechanical
and physical properties)
• The two alloys are:
• Ti 6AL-4V
• Ti 6AL-4V-ELI (Extra low interstitial alloys)
• Commercially pure Ti is a light metal with excellent biocompatibility,
relatively high stiffness and high resistance to corrosion.
II. Ceramics
• Ceramics were first introduced to implant dentistry in the form of
coatings onto metal-based endosseus implants to improve
osseointegration.
• Ceramic coatings.
a. Bioactive ceramics e.g. CaP (Plasma-sprayed dense HA, FA)
b. Inert Ceramics e.g. Al₂O₃, ZrO.
• Examples: Alumina, Hydroxyapatite, B – Tricalcium phosphate, Carbon
e.g. low/ultralow temperature Isotropic, Bioglass, Zirconia, Zirconia –
toughened aluminia.
• Methods used for coating:
• Plasma spraying
• Sputter deposition
• Sol-gel coating
• Electrophoretic deposition
• Biomimetic precipitation
III. Polymers
• Polymers are softer and more flexible than other classes of
biomaterials.
• Examples: PMMA, Polytetrafluoroehylene (PTFE), Polyethylene,
Polysulfone, Polyureltane.
• They are also present with low mechanical strength, which makes
them prone to mechanical fractures during function under high
loading forces.
• Polymeric materials were reported to have very little application in
implant dentistry and were only used to fabricate shock-absorbing
components placed between the implant and the suprastructure.
Osseointegration
• A direct structural and functional connection between ordered living
bone and the surface of a treated implant, which is visible under the
light-optical microscope. (Branemark 1952)
• A time-dependant healing process where by clinically asymptomatic
rigid fixation of alloplastic materials is achieved, and maintained, in
bone during functional loading. (Zarb & Albrektson,1991)
• Relies on an understanding of
• Tissue healing and repair
• Tissue remodelling
• Effects of force in all vectors
• Immune response to the insertion of foreign bodies
Factors affecting osseointegration
1. Biomaterials: Those that form intimate bonds with bone include
CPTi, Zirconium, Ceramics.
2. Implant designs: Implant length, diameter, geometry and threads.
a) Implant length: It varies from 6-20 millimetres. Longer implants
guarantee better success rates and prognosis, while shorter implants
have lower success rates due to reduced stability.
Short or narrow implants are preferred for the prosthetic solution of
the extremely resorbed alveolar bone areas.
Factors affecting osseointegration
b) Implant diameter: Typically ranges from 3 to 7 millimetres. Wider
implants allow for interaction with a larger amount of bone. They are
more stable and can resist larger vertical loads.
c) Implant geometry: The implant geometry/shape affects the
interaction between the bone and implant, the surface area, the
distribution of forces to the bone and the stability of the implant.
The main types are cylindrical, conical, stepped, screw-shaped and
hollow cylindrical. Cylindrical screw threaded implants are the most
commonly used because they result in lower stresses.
Factors affecting osseointegration
d) Implant threads: Threads are incorporated into implants in order to
improve initial stability, enlarge implant surface area, distribute stress
favourably while minimizing the amount of adverse stresses to the
bone-implant interface.
3. Biomechanical factors: Inadequate initial stability usually results in
high failure rate.
Major contributors to biomechanical stabilities are the design
parameters such as length, diameter, geometry and threads. Other
factors are material properties, quality and quantity of surrounding
bone, masticatory forces.
Factors affecting osseointegration
4. Surface characteristics: Surface properties such as morphology, topography,
roughness, chemical composition, surface energy, residual stress, the existence
of impurities, thickness of Ti oxide film, and the presence of metallic and non-
metallic compounds on the surface affects the success rate of dental implants.
• Osteoblastic cells adhere more quickly to rough surfaces than to smooth
surfaces.
• Two methods for alteration of implant surface roughness are :Additive or
Subtractive. In additive, a biocompatible material such as titanium plasma-
sprayed coating is added to the implant surface while in subtractive some
material is removed from the implant surface by blasting and/or acid etching.
Factors affecting osseointegration
• Two broad types of chemical alterations are:
1. Addition of inorganic phases (e.g. hydroxyapatite or calcium
phosphates)
2. Addition of organic phases (growth factors).
• The addition of inorganic phases such as calcium phosphates imparts
osseoconductive properties to the implants.
5. Medical status of the patient: Systemic risk factors can increase the
risk of the treatment failure or complications.
Factors affecting osseointegration
6. Bone quality: Bone generally classified as either compact (cortical) or
cancellous (trabecular). Poor bone quality results in higher risk of
implant failure. Implant placed in the maxilla have higher failure rate
than those in the mandible.
7. Surgical technique: Atraumatic surgery-to minimize mechanical or
thermal tissue damage. Temp.>47degree C during implant
surgery→Cell death& denaturation of collagen→Fibrous formation.
8) Loading: Excessive mechanical load can result in breakdown of the
bone-implant interface.
Implant Loading
• Implant loading may be classified as immediate, early or conventional.
• Immediate implant loading: when the implant is exposed to loading
earlier than one week following implant placement.
• Early implant loading: when loading is applied within one week to two
months subsequent to implant placement.
• Conventional implant loading: when the load is applied after an
unloaded healing period of at least two months subsequent to
implant placement.
Terminologies Used in Endosseous implant.
• Implant Fixture: : A device inserted into the jawbone to support a
dental prosthesis. It is the ‘tooth root’ analogue.
• Cover screw: : A screw cover placed on the implant during the
healing phase after the stage I surgery. It is removed when locating
the abutment. It prevents bone ingress in the implant head.
• Transmucosal Abutment(TMA): Used to link the implant to the
prosthesis. 4 basic types are Cylindrical, Shouldered, Angled.
Customizable.
Terminologies
• Healing Abutment: Placed temporarily on the implant to maintain the
patency of the mucosa penetration
• Normally wider than the corresponding regular abutment to
compensate for some tissue collapse into the space when placing the
regular abutment.
• They also allow for a period of resolution of tissue swelling before
selecting the final abutment so as to ensure its optimal height.
Terminologies
• Healing cap: A dome shaped screw placed after stage II surgery and before the
prosthesis placement. It usually projects through the soft tissue into the oral
cavity.
It may screw directly into the implant(root form) then called healing abutment
or onto the abutment.
• Impression Post: This facilitate the transfer of the intraoral location of the
fixture or the abutment to the laboratory cast.
May be screwed directly into the fixture or onto the abutment.
• Laboratory analogue: Exact replica of the implant fixture or the abutment in the
laboratory. It screws onto the impression post after it is removed from the mouth
and placed in the impression before pouring.
Stages in implant treatment
There are 3 basic steps in implantology:
Step 1: The Fixture Operation: The titanium fixtures are placed in the jaw
bone and covered by the mucosa.

Step 2: The Abutment Operation: This is a minor surgical procedure which

involves the attachment of special titanium pillars (abutments) to
the fixtures after exposure of the implant head.

Step 3: The Prosthetics: This is the stage of construction and fitting of new
teeth ( superstructure).
Treatment Planning Phase
• Diagnosis begins with a complete patient evaluation.
• Treat the entire patient.
• Restore form, function and aesthetics.
• Initial patient evaluation: Hx(Med., Dent, Soc, Habit.)
A systematic & thorough clinical exam.
Extra/ Intra oral exam(Soft & Hard tissues )
Evaluation of the existing prostheses, the intended implant site.
Diagnostic Impression/ Study Cast.
Radiographs
Lab. Investig.(Haem.,Chemical,HIV, HbSAg etc)
The Teeth
• Number and existing condition:
• Minimum 6-7mm between teeth to facilitate implant placement
• >1.5mm between implant and natural teeth
• 7mm from centre of implant to centre of implant for edentulous
• More than 10mm mesiodistal space- single tooth implant not recommended
• Prognosis of remaining teeth
• Tooth and root angulations and proximity
• Mesiodistal width of the edentulous space
The implant site
Clinical Assessment of the implant site involves : Observation, Inspection,
Palpation.
• To detect flabby tissue, narrow bony ridges, undercuts all of which may limit
implant placement.
• Width of residual alveolar ridge should be assessed clinically—thickness of
overlying ridge mucosa can be estimated using probe with a stopper facially &
lingually. Then deduct this from the clinical width of the whole alveolar ridge
facio-lingually will give you a rough estimate of the thickness(width) of the bone.
• No of implants.
Implant site assessment
• Soft tissue quality & quantity: Sufficient band of keratinised mucosa
will :
Improve the aesthetic outcome of the definitive implant-supported
restoration.
Minimise the post op gingival recession.
Endure the trauma of brushing.
Resist masticatory muscle pull.
Reduce the probability of soft tissue dehiscence above the implant
fixtures
Radiographic Assessment
• Of the planned implant site is necessary to:
• Assess the approximate bone height – to determine the implant
length. (normally from 6 mm - 20mm but short implants are now
available)
• Assess the adequacy of bone (quantity &quality).
• Assess proximity to anatomical structures.
• Obtaining multiple views of proposed implant site(s) usually
necessary for adequate assessment of bone height and width
• Periapical and occlusal views- of some value
Radiographic Assessment
• Periapical may show approximate height of the bone & bone quality- density and
quantity.
• Good occlusal shows the buccal and lingual cortices of the mandible-width.
• These 2 views show the least distorted image of the site
• Panoramic view – the minimum standard to assess bone height, proximity to
sinus or inferior alveolar canal.
• Gives a general view of both jaws and the jaw relationship
• They are needed also in determining the arch width, relationship to the sinuses,
nasal floor, incisive foramina and inferior alveolar canals.
• Helpful in determining the length of implant to be used.
Radiographic Assessment
• Advantages of Panoramic:
- Allow comparison with contralateral side
- May reveal problems/pathologies such as cysts/tumours , condylar changes etc.
- Useful for preliminary assessment of multiple implant sites.
- Disadvantages;
- Extremely sensitive to errors in pt’s position
- Distortion is a major problem- magnification of 5%-35% do occur.
- Does not give info on the width of the bone especially in the anterior area
• Lateral cephalometric films: for bone width not revealed on
panoramic eg. In anterior maxilla or mandible.
• Specialised CT Scans:
• Useful with its two dimensional and 3 dimensional reconstruction capabilities.
• It is precise for presurgical assessment.
• With the aid of software packages for processing the info obtained from these scans they are very
useful- in fact the most useful for preop assessment of implant site.
• However Cost is a limiting factor.
• May be cost-effective if multiple sites in both jaws are involved.
Examples:
• Dentascan visualizes true cross-section of mandible and maxilla .
• 3D reconstruction and Stereo -Lithographic Models are recent facilities but requires a software-
eg SIPMLANT therefore expensive.
Bone Quality
Classification(Lekholm&Zarb,1985)
• Type I
Composed of homogenous compact bone, usually found in the anterior mandible
• Type II
A thick layer of cortical bone surrounding dense trabecular bone, usually found in the
posterior mandible
• Quality III
A thin layer of cortical bone surrounding dense trabecular bone, normally found in the
anterior maxilla but can also  be seen in the posterior mandible and the posterior maxilla.
• Quality IV
A very thin layer of cortical bone surrounding a core of low-density trabecular bone, It is
very soft bone and normally found in the posterior maxilla. It can also be seen in the
anterior maxilla.
Bone quality
Bone quantity
• 6mm or below buccal-lingual width with sufficient tissue volume.
• 8mm interradicular bone width
• 10mm alveolar bone above IAN canal or below maxillary sinus
Aesthetic Analysis
• Smile Line- High in Max. , Low in Mand.
• Lip Shape – Full vs Thin
• Existing ridge defect: If visible with high smile line will need ridge
augmentation.
• Restored implant should appear to emerge from the gingiva
• Produce a natural and desirable appearance
Pre operative Models
• Made of super hard die stone.
• Should reproduce the fine details of the occlusal surfaces, gingivo-
buccal fold and retromolar areas.
• The need for augmentation may be observed at this stage.
• Skull-related , articulated preop models are prerequisite of model
analysis.
Occlusal Analysis
• Diagnostic cast is mounted to
determine opposing occlusion
Assess : the ridge width, the
existing inter arch vertical space(14-
15mm for complete dentures,
partially edent. varies by implant type.
• Maxillo-Mand relationship
(Class 11 may have benefits. Class 111
requires surgical intervention)
Diagnostic Wax-up
• A diagnostic wax up of the missing tooth and jaw records should
precede every prosthetic restoration.
• Helps in planning the optimum functional and aesthetic tooth
positioning.
• Atrophied jaw bone can be recognised and augmentative measures
for an implant –retained prosthetic restoration diagnosed in time.
Planning Template
• Fabricated using a vacuum forming procedure or with cold/heat
curing polymer.
• Used to determine the planned implant position in the jaw.
• May subsequently be extended to become a radiographic and drill/
surgical template.
• The surgeon uses the drill template to conduct the pilot drilling. Used
as a guide for optimal B/L and M/D positioning
Informing The Patient
• Patient Education.
• Treatment options
• Multidisciplinary approach.
• Long-term commitment
• Surgical and Restorative procedures
• Maintenance and regular recall
• Expected time between surgery and delivery of finished prosthesis
• Potential short and long term risks / complications e.g. Nerve injury, infection, implant failure
• Fee and payment policy
• The informed consent
• Plan for temporization
Implant Placement Techniques
1. Two-stage procedure (submerged technique)
2. One-stage procedure (non-submerged technique)
Advantages of one-stage procedure:
• the avoidance of a second surgical procedure.
• the lack of a micro-gap at the bone crest level, resulting in a less crestal
bone resorption.
• the prosthetic procedure is simplified and less chair time per patient is
required.
• a non-loaded, immediate or delay-loaded protocol can be implemented.
(a) two-stage and (b)one-stage implant placement
methods.
Note the trans-mucosal (the neck) part penetrating the
overlying soft tissue in the one-stage method.
• Placement of Implant
• Immediate: Just after tooth extraction.
• Standard : Placed weeks to a few months after tooth extraction.
• Delayed: Much later.
The Surgical Procedure
Pre-op medication.
Conscious sedation if necessary
• Preoperative antibiotics: oral - 1 hour before (2gm PencillinV. Or
Clindamycin 300mg . Or Amoxycillin 1gm)
Parenteral; i.m. – 30 minutes before -Crystall Pen. 1 mega
unit(600,000 I U).
i.v. - just few minutes before the incision. (I mega unit of Pen G
or 1 gm of or Cefazolin ceftriazone)
Anti-sepsis and Anaesthesia
ANTISEPTIC Preparation
• Adequate antiseptic preparations of surgical site. 0.12% chlorhexidine mouth
rinse for 30 – 60 seconds immediately before anaesthesia reduces microbial
count.
• A peri oral facial prep with iodine or chlorhexidine based antiseptic solution.
• Field isolated with sterile towels + sterile instrumentation.
• Surgeon and assistants should follow sterile procedures-masks sterile gloves &
gowns.

• Profound anaesthesia necessary - block can be combined with local infiltration

Incision
• A mid-crestal incision with vertical relieving incisions (if closed to
adjacent teeth including inter-dental papilla).

• A mucoperiosteal flap is raised.

• The flaps should be elevated sufficiently far apically to reveal any

bone concavities, especially at sites where perforation might occur.
Edentulous jaw for implant Markings for incision

i
Mid crestal incision Mucoperiosteal flap

.
Marking of Potential implant site.
• Implant site is located after exposure of the bone using
the surgical guide template – a clear acrylic mould of the
arch.
• This may also assist in directing the drill angulations.
• A pilot drill is used to drill through the acrylic surgical
stent to mark the site of implant on the bone
Bone Drilling
• A pilot drill or a 2mm twist drill is used to perforate the cortex at the
alveolar crest and make the initial pilot hole.
• A narrow cylindrical hole is drilled in the bone to the required depth(based
on the length of the implant ) using the twist drill.
• Using a special depth gauge , the depth of the preparation is measured.
• A paralleling pin is placed in the prepared hole to check the alignment and
angulations.
• Preparation commence with
Initial penetration.
• Pilot drill
guide pin is placed to
check the direction
Check the final depth
with a depth gauge
Bone drilling
• This is done in sequence following the manufacturers guide to make proper sized
drill hole for the particular implant.
• Atraumatic preparation with a low speed(1500-2000rev/min, high torque
handpiece and vigorous irrigation are required. This is to prevent thermal injury.
After the first drill ( pilot drill) is used to perforate the cortex and create the initial
pilot hole, the drills are used in ascending order of diameter/thickness until the
size of the implant is reached.
The drills have markers for depth to guide the surgeon. When the required depth is
reached it is checked with the depth gauge.
Implant Spacing & Angulation
• Check the spacing and angulation of the implant sites carefully with
direction indicators throughout the drilling sequence

• Angulations of the implants should be consistent with the design of

the restorations
Implant Placement
• Implants are in sterile packs with the implant carrier - the threading
surface should not be touched by instruments or hand.
• The implant carrier is used to carry the implant to the site and the
rachet is used to thread and screw it into place (the required depth).
• The implant carrier is removed and the healing or cover screw is
inserted on top of the implant to cover it.
Implant Placement
Implant should be placed such that;
• It is within bone along its entire length.
• It does not damage adjacent structures such as teeth, nerves, nasal or sinus
cavities.
• Multiple implants should be placed in fairly parallel arrangement.

• The top of implant should be placed sufficiently under the mucosa to

allow a good emergence profile( eg 2-3mm apical to labial CEJ of adj.
teeth)
Allowances should be made between the implant and the following structures:
Buccal plate surface 0.5 mm.

Lingual plate surface 1.0mm

Maxillary sinus 1.0mm

Incisive canal avoid midline of maxilla

Nasal cavity 1.0mm

Inferior alveolar canal 2. 0 mm. From superior aspect of the canal

Mental nerve 5. 0 mm from anterior of the bony

foramen.

Adjacent natural tooth 0.5 mm

Between 2 implants 3.0 mm
• Cylindrical implants are either
pushed or gently knocked into
place.

• Screw shaped implants are

either self tapped into the
prepared site or inserted
following tapping of the bone
with a screw tap.
Wound closure
• The mucoperiosteal flaps are
carefully closed with multiple
sutures either to bury the
implant completely or around
the neck of the implant in non-
submerged systems.

• Silk sutures are satisfactory and

others such resorbables are
good alternatives.
Post op radiograph
• Take Postoperative
radiographs(Periapicals) to
evaluate implant position in
relation to adjacent structures.

• Also for monitoring the

ossteointegration.
Misplaced Implant
• Any deviation from the optimal positioning of the implant in any
dimension will surely result in an aesthetic problem.
• Causes include: i) use of an imprecise surgical template. ii) Instability
of the angulation of the H/P . Iii) Lack of knowledge/ experience.
• Position too far apically Formation of a deep gingival sulcus
Bacterial colonisation
• Accessibility to the prosthetic margin becomes difficult.
• Gingival bleeding
• Gingival recession
• Correction of this dilemma is almost impossible. Strict maintenance of
O/H will reduce the tendency for gingival inflammation.
• Placing an implant too far incisally will result in short crown with
constricted margins.
Post op Care & Instructions
• Haemostasis
• Medications
– Dalacin C 300mg 12hourly for 5 days
– Tab vitamin C 1g daily for 2weeks
– IM Paracetamol 600mg stat
– Tabs Diclofenac 50mg 12hourly for 3days
• Ice packs to reduce swelling and pain
• chlorhexidine 0.2% mouthwash
• Avoid smoking and alcohol
Temporization
• A restorative temporization procedure immediately follows after
implant placement surg.
• Provisional prosthesis should be designed to sustain/ improve the
quality of life of patients.
• Acts as a reference in designing the final pros.
• 0ptions include RPD, RBB, Temporary implants.
RPDs
• Acts as a stimulus for bone remodelling around dental implants in
totally edent. pxs.
• Can be used to confirm osseointegraton b4 the final prosthsis is
constructed.
• Must be relieved from its fitting surface on top of the implant head to
avoid any biting load being exerted on the implants during healing
period.
• Maintain the elasticity of the fitting surface by changing the lining mtrl
at monthly intervals.
• Problem: Instability.
RBB
• Does not exert any pressure on the implant area.
• Better tolerated and more reassuring b/c of its improved aesthetics
stability & fixation.
Temporary Implants
• Commercially available.
• Self tapping screws that have a diam. ranging bw 1.8 & 2.8mm.
• Come in various lengths.
• Inserted thro. A one-stage drilling procedure using only a pilot drill with minimal
surgical intervention.
• They should be placed at least 1mm from the site of the perm. Implants to avoid
interrupting osseointegration around the implant-bone interface.
• They can be easily removed by reversed torque or by using a small drill after the
completion of the healing period for perm implants.
Temporary Implants
• Adv. : Provision of immediate function after implant placement.
• Uneventful soft tissue healing on top of the perm. Implant.
• Restoration of phonetics & aesthetics.
• Disad. Improper placement can cause damage to a previously
reconstructed alv. ridge or jeopardize osseointegration.
• Lack of space may prevent their use for rest. of a single missing tooth.
Complications of Implant Surg.
• Intra operative:
• Tear of flap.
• Insufficient irrigation thermal injury to bone.
• Perforation of buccal or lingual cortex
• Impingement on inferior dent canal/ nerve.
• Impingement on adjacent tooth.
• Perforation of maxillary sinus,
• Lack of primary stability.
• Fracture of implant.
Complications(cont.)
• Immediate post-op:
• Pain ( rare)
• Haemorrhage( also rare)
• Swelling
• Nerve injuries.

• Delayed:
• Infection
• Secondary Haemorrhage.
• Nerve injury.
• Loosening of implant & Loss of implant
Long term complications
• Anatomical
• Neurological
• Deintegration
• Progressive thread exposure
• Gingivitis
• Hyperplastic tissue
• Fractured Implant
1. Loss of bone anchorage
a. Mucoperiosteal perforation
b. Surgical trauma
2. Gingival problems,
a. Proliferative gingivitis
b. Fistula formation
1. Complications in stage I surgery
• Mental nerve damage
• Penetration into a sinus, nasal cavity, or through inferior border of the mandible.
• Excess countersink.
• Thread exposure.
• Eccentric drills, taps.
• Jaw fracture.
• Ecchymosis, more common in older patients.
• Wound dehiscence.
• Facial space abscess submental, submandibular, Ludwig’s angina.
• Suture abscess.
• Loose cover recovery.
2. Complications in stage II surgery
• Poor selection of fixture height.
• Incorrect fixture placement more than 35° cannot be used prosthetically.
• Damaged hex nut on top of fixture.
• Loose abutment.
• Fractured abutment screw.
• Early loading by prostheses.
• Poor air-flow pattern with “high-water” design.
• Aspiration of instruments
• Thread exposure.
• Fixture fractures.
• Excess bone resorption.
• Plaque/calculus formation, periodontal problems.
• Poor selection of abutment height.
3. Mechanical complications
a. Fracture of prosthesis, gold screw,
abutment screw
3. Prosthetic complications
• Insufficient space beneath the fully bone anchored prosthesis.
• Abutment penetrate through alveolar mucosa.
• Screw fractures: gold or abutment screws.
• Acrylic or porcelain fracture.
• Posterior fixture failures in the maxilla
Ossteointegration time
2nd Stage Surg.
• Confirm osseointegration clinically and by Xray
• Uncover the implant & place the TM healing abutment.
• Implant can be uncovered through a tissue punch technique or a
crestal incision over the implant. Crestal incision after LA infiltration.
• Healing phase 4-6weeks
• Replace healing abutment with final abutment.
• Check its fit by X-Ray
•.
Direct/Open-tray/Pick-up Impression Technique

Indications
• Single tooth, or multi-units restorations.
• Implant overdentures.
• Cement/screw retained prosthesis.
• Non parallel inserted implant
• Deeply located implant shoulders
Advantages
• The dentist can confirm the laboratory preparation and contour of the
provisional prosthesis to achieve the desired healing and soft tissue
contour before final crown fabrication.
• More accurate for the multi units.
Disadvantages
• More time spent for impression making.
• Test fitting impression copings and cutting holes for the impression
copings.
• Additional time to “unlock” the impression copings.
• Adequate mouth opening required.
• More possibility for gagging.
Direct technique subdivided into :
Splinted Technique
Non splinted Technique
• Splinting is recommended in case of multiple implants to decrease the
amount of distortion and to improve accuracy and implant stability
• The use of rigid material for splinting is essential for accurate master
cast.
 Materials used for splinting
• Light cured composite
• Acrylic resin (heat and self cure)
• Impression plaster.
Snap-fit (Press fit)

- Uses press-fit impr. coping connected to the implant instead of screwing

- The plastic impr. copings are picked up in the impr.
- The technique is not a pick-up impr. because it does not require an open
tray but instead uses a closed tray.
- It is not a transfer impr either because the plastic impr copings are
picked-up in the impr.
Advantages
- Helps to overcome the movement of impression coping inside the
impression material
- Time saving
- Has the advantage of both the open and closed tray implant impression
techniques
- More comfortable for both the clinician and the patient
- Easy to manipulate
Abutment Level Impression Techniques
• Direct
- Preparable abutments are usually supplied in various materials such
as alumina, Zirconium, Titanium.
- The manufacturer typically supplies these as stock shape abutments,
which can be placed directly on the implants and modified by the
clinician in the mouth.
- The technique of preparing them is similar to traditional crown and
bridge techniques.
- Preparation can be carried out directly in the mouth.
- This will allow the margins of the abutment to follow the gingival
contour.
- Utilizing standard crown and bridge principle, an impression can be
recorded of the abutments directly in the mouth.
• Indirect
- Attach the abutment to the implant.
- Seat plastic impression copings on the abutment so that click sounds
are heard.
- Inject the material around the coping.
- Lead the tray and place it on the coping until the tray is fully seated.
- After setting, remove the tray
- insert the abutment analogs into the coping, embedded in the impr, so
that the click sounds are heard again.
Gingival (Soft Tissue) Mask
• For the optimum design of the implant-retained C& B restorations, a
removable ging. mask is fabricated on the master cast using silicone mtrls.
• Adv. : Allows unimpeded view of the impl. Analogue.
• Accuracy of the fit of the superstructure can be checked.
• Precise reproduction of the ging. margin.
• Allows the design of the prosthetic restoration according to the ging.
outline.
• Allow fabrication of the superstruc. that are convenient to clean from a
periodontal standpt.
Cover screw in place
• Exposure of implant with
minimal flap reflection.
• Removal of the cover screw.
Insertion of the impression post
Impression taking (Elastomer) Placement of the implant Analog.
Cast and gingival mask fabrication
 Selection of abutment:
1) Prefabricated abutment

2) Custom fabricated
Abutment 3) CAD/CAM fabricated
Further laboratory work.

• Wax up of the superstructure

• Fabricate the framework
• Venering(porcelain baking)
 Finishing and cementation.

The completed, metal-ceramic superstructures

Features of Cement & Screw retained
Restorations
Cement-retained Screw- retained

Retrievability Not easy Yes

Aesthetics Excellent Variable

Correction of misaligned Implant Usually Sometimes

Ease of Insertion Conventional techniques Difficult in posterior areas

Retention at minimal occlusal Marginal Excellent.

height
Passive Fit Yes Questionable

Maintenance Minimal Moderate

Success criteria
• According to Harvard success Criteria for Dental implant, Dental
implant must provide functional service for 5 years in 75% of cases.
• Criteria are both subjective and objective.
Subjective Criteria
• Adequate function
• Absence of discomfort
• Improved aesthetics
• Improved emotional and psychological wellbeing
Objective Criteria
• Bone loss no longer than 33% of vertical length of implant
• No peri-implantitis
• No associated radiographic radiolucency
• Marginal bone loss 1.0-1.5mm first year; then < 0.1mm annually thereafter
• Good occlusal balance and vertical dimension
• Gingival inflammation amendable to Rx
• Mobility of less than 1mm in all direction
• Absence of symptoms of infection
• Absence of damage to surrounding structure
• Healthy connective tissues
Maintenance of implant
• Primary goal is to protect and maintain “tissue-integration”;good oral hygiene is a key element!
• Implant patients should be thoroughly instructed in maintenance therapy with the understanding that the
patient serves as co-therapist
• Home-care regimen periodic recalls reinforcing regimen
• strict adherence to recall schedule & verification of function, comfort, and aesthetics.
• immediate post-delivery
• 24 hours
• one week
• one month
• 6 months
• bi-annual or annual evaluation

• lifetime maintenance commitment

Failure of Implants
• El askary et.al have divided the failures into seven categories:
1 According to etiology Failures because of host factors
 Medical status - Osteoporosis and other bone diseases; uncontrolled
diabetes.
 Habits - smoking, para-functional habits.
 Oral status - poor home care, juvenile, and rapidly progressive
periodontitis, irradiation therapy.

A) Restorative problems Excessive cantilever, pier abutments, no passive fit, improper fit of the
abutment, improper prosthetic design, improper occlusal scheme,
connecting implants to natural dentition, premature loading, excessive
torquing.

B) Surgical placement Off axis placement (severe angulation)

 Lack of initial stabilization
 Impaired healing and infection because of improper flap design or
others.
 Overheating the bone and exerting too much pressure.
 Minimal space between implants
 Placing the implant in immature bone grafted sites.
 Placement of the implant in an infected socket or a pathologic lesion.
 Contamination of the implant body before insertion.

C) Implant selection
Improper implant type in improper bone type.
 Length of the implant (too short, crown-implant ratio unfavourable)
 Diameter of the implant.
2 According to origin of infection Peri-implantitis (infective process, bacterial origin)
–  Retrograde peri-implantitis (traumatic occlusion origin, non-infective, forces off the
long axis, premature, or excessive loading).

3 According to timing of failure – Before stage II (after surgery)

 At stage II (With healing head and or abutment insertion)
 After restoration.

4 According to condition of Ailing implants

failure (clinical and  Failing implants
radiographic status)  Failed implants
 Surviving implants

5 According to responsible Dentist (oral surgeon, prosthodontist, periodontist)

personnel –  Dental hygienist
 Laboratory technician
 Patient.

6 According to failure mode - Lack of osseointegration (usually mobility)

 Unacceptable esthetics
 Functional problems
 Psychological problems.

7 According to supporting tissue Soft tissue problems (lack of keratinized tissues, inflammation, etc.)
type –  Bone loss (Radiographic changes, etc.)
 Both soft tissue and bone loss.
Conclusion
• Dental implant is one of the defining advances in clinical Dentistry,
therefore, dental professionals must comprehend the surgical and
restorative protocols involved in successful implant treatment ,in
order to confidently recommend dental implants as the standard of
care ,to improve the patient’s well being and psychosocial life .
References
• Stuart H. Jacobs and Brian C. O’Connell Dental Implant Restoration Principles and Procedures
2011. Quintessence publisher.
• John A. Hobkirk, Roger M. Watson and Lloyd J.J Searson introducing Dental Implant 2003.
Churchhill livingstone Publisher.
• Ivoclar Vivadent Competence in Implant Esthetics, Manual of Implant Superstructures for Crown
and Bridge Restorations. 2010 Pennwell dental Group
• Albrektsson el ta The longtime efficacy of current Used Dental Implant: A review and Proposed
Criteria of success. 1997
• Sanjay CHAUHAN, Dental Implant Surgery, Rewari 1999
• Abd El Salam El Askary Reconstructive Aesthetic Implant Surgery. 2003 Blackwell Publisher.
• Sanda Moldovan. A comprehensive Review.dentalcare.com Continuing Education Course.2013
• ETC.
Sanjay CHAUHAN