DENTAL IMPLANTOLOGY

Ibrahim H. Bashier Garoushi

BDS., MSc., MFDRCSI.
 INTRODUCTION
• In 1952, Brånemark conducted an experiment where he
utilized a titanium implant chamber to study blood flow in
rabbit bone .
• In 1965, Brånemark placed his first titanium dental implants in a
patient’s mouth (Gösta Larsson )
Radiograph of Branemark’s initial rabbit specimen, showing the titanium
optic chamber fixed to the rabbits tibia and fibula.
 PERI-IMPLANTATION BIOLOGIC AND

FUNCTIONAL CONSIDERATIONS
A. Soft Tissue to Implant Interface:
o The soft tissue barrier around an implant or abutment is important for
maintenance of implant stability and long-term clinical function, since it
protects the integrity of the bone–implant interface.
o The morphology of the barrier resembles that of gingiva around teeth and
contains a sulcus epithelium, a contact epithelium followed by a zone of
connective tissue down to the marginal bone.
o One major difference compared with gingiva is the direction of the
collagen fibers which seem to run parallel with the implant/abutment
surface, while perpendicular fibers are also present at teeth.
• Osseointegration: Formation of a direct interface between an
implant and bone.
 PERI-IMPLANTATION BIOLOGIC AND

FUNCTIONAL CONSIDERATIONS
B. Hard Tissue Interface:
• The primary goal in implant placement is to achieve
and maintain an intimate bone-to-implant
connection. This concept is known as
osseointegration
• Osseointegration clinically is defined as the
asymptomatic rigid fixation of an alloplastic
material (the implant) in bone with the ability to
withstand occlusal forces
 PERI-IMPLANTATION BIOLOGIC AND

FUNCTIONAL CONSIDERATIONS
• Bone tissue responses to implants

o The bone healing process around a dental implant resembles that of

normal bone healing. The surgical trauma created during the insertion of
an implant initiates an immediate and preprogrammed healing response
at the bone–implant interface.

o Healing by ankylosis (no PDL).

 Sectioned view of implant

interface and adaptation over time

 Osseointegration
• For osseointegration to occur in a predicable
fashion, several important factors are required:
1. A biocompatible material (the implant).
2. Atraumatic surgery to minimize tissue
damage.
3. Implant design.
4. Submerged or nonsubmerged protocols.
5. Loading conditions.
6. Bone factors.
7. Prosthetic considerations.
 Osseointegration
1. A biocompatible material (the implant).
o Most current dental implants are made of
commercially pure titanium. It has established a
benchmark in osseointegration.
o Titanium is the material of choice for dental implants.
o Titanium form an intimate bond to bone.
o Titanium is biologically inert and therefore does not
elicit a foreign body rejection reaction from host
tissue.
o High strength.
o High corrosion resistance.
 Osseointegration
• Materials used for dental implant

A. Metallic materials Ceramic materials

1. Titanium pure and titanium 1. Non-reactive ceramics
alloys (most commonly used) 1. Alumina.
2. Surgical stainless-steel alloy. 2. Sapphire.
3. Cobalt-chromium- 3. Zerconium, Tungesten and Carbo
molybdenum alloy.
2. Reactive (bioactive) ceramics
1. Hydroxy apatite.
4. Metals with surface coatings 2. Bioglass.
 Osseointegration
2. Atraumatic surgery to minimize tissue
damage.
a. Aseptic environment.
b. Using sharp, precision osteotomy drills run at slow speed with high
torque.
c. Maintaining gentle, intermittent pressure.
d. Providing copious irrigation. Irrigation can be accomplished either
externally or internally using special handpieces and burs with internal
ports. The goal is to maintain bone temperatures below 47 degrees
Celsius (°C) during implant site preparation. Any variance causing
temperatures to exceed 47°C is likely to cause bone necrosis and
failure of osseointegration.
 Osseointegration
3. Implant design:
• The implant design has a great influence on
initial stability and subsequent function in
bone. Following are the main design
parameters:
a. Implant length:
o Implants are generally available in lengths from about 6 mm to as much
as 20 mm. The most common lengths employed are between 8 and 15
mm.
 Osseointegration
b. Implant diameter:
o Most implants are approximately 4 mm in diameter. A diameter of at
least 3.3 mm is normally recommended to ensure adequate implant
strength.
o Implants of 3 mm diameter are now available and normally
recommended for low load situations such as mandibular incisor teeth.
Narrow implants may have to be designed as one piece (i.e.,
incorporating the abutment).
o Wider diameter implants (5 mm and over) are often indicated for molar
replacement.
Implant length and
diamter
 Osseointegration
c. Implant Shape:
o Most implants are parallel cylindrical or tapered cylindrical threaded
designs, and may be smooth or have cutting faces to achieve self-
tapping of the bone.
o The thread design and pitch vary considerably. A common thread pitch is
0.6 mm. The thread design may be more rounded or sharp and contribute
to stability of the implant on insertion.
o The outer surface profile of the coronal end may have the same thread
profile as the body of the implant, a finer microthread or a smooth profile.
The abutment connection to the implant may be within the implant
(internal connection) or sit on top of the implant (external connection).
Internal and external
connection
 Osseointegration
d.Surface characteristics:
Types of surface treatment of
dental implants:
1. Titanium plasma-sprayed coating.
2. Sandblasting and then surface acid etching.
3. Oxidation treatment laminates a titanium oxide on the titanium implant
surface to form an irregular implant surface.
4. Mechanical polishing treatment smoothes the implant surface to
increase the contact area with the bone.
5. Laser induced surface roughening.
6. Hydroxyapatite coating.
Implant surface treatment
 Osseointegration
4. Submerged and Nonsubmerged protocols:
I. Submerged protocol:
o The classic submerged system was the original protocol as
described by Branemark.
o Implants are installed with the head of the implant and
cover screw level with the crestal bone and the
mucoperiosteal flaps closed over the implants and left to
heal for several months.
o This had several theoretical advantages:
a. Bone healing to the implant surface occurs in an environment
free of potential bacterial colonization and inflammation.
b. Epithelialization of the implant-bone interface is prevented.
c. The implants are protected from loading and micromovement
that could lead to failure of osseointegration and fibrous tissue
encapsulation.
Non submerged and
submerged protocols
 Osseointegration
o The submerged system requires a second surgical procedure after a
period of bone healing to expose the implant and attach a transmucosal
abutment –healing abutment-(two stage surgery).
o The initial soft tissue healing phase would take a period of approximately
2-4 weeks. Abutment selection would take into account the thickness of
the mucosa and the type of restoration.
 Osseointegration

(A). 4.1-mm-diameter tissue (B) A closure screw has been placed

level Straumann implant has on top of the implant and the flaps
been placed so that the are sutured around the collar to
polished collar is above the leave the head of the implant
crest of the bone exposed in a nonsubmerged fashion
 Osseointegration
5. Loading conditions:
I. Delayed loading:
a. Two-stage surgical protocol
b. One-stage surgical protocol
o The original Branemark protocol then advised leaving
implants unloaded and buried beneath the mucosa for
approximately 6 months in the maxilla and 3 months in the
mandible, due mainly to differences in bone quality.
o Nowadays the majority of delayed loading protocols
recommend a maximum 3 months healing period for both
jaws.
 Osseointegration
5. Loading conditions:
II. Immediate loading:
a. Immediate occlusal loading.
(placed within 48 hours post-surgery).

b. Early loading (from 1 week to 8 weeks).

 Osseointegration
6. Bone factor ( bone quality and quantity):
• The simplest categorization of bone quality is that described by Lekholm as 4
types:
• Type I:
o Composed of homogenous compact bone, usually found in the anterior lower jaw.
• Type II:
o Had a thick layer of cortical bone surrounding dense trabecular bone, usually found
in the posterior lower jaw.
• Type III:
o Had a thin layer of cortical bone surrounding dense trabecular bone, normally
found in the anterior upper jaw but can also be seen in the posterior lower jaw and
the posterior upper jaw.
• Type IV:
o Had 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 upper jaw. It can also
be seen in the anterior upper jaw.
 Osseointegration
6. Bone factor( bone quality and quantity):
o Types 2 and 3 are the most favorable quality of
jaw bone for implant treatment. These types
have a well-formed cortex and densely
trabeculated medullary spaces with a good
blood supply.
 Osseointegration
7. Prosthetic Loading Consideration:
o Carefully planned functional occlusal loading will
result in maintenance of osseointegration. In contrast,
excessive loading may lead to bone loss and/or
component failure.
o Clinical loading conditions are largely dependent on
the following factors:
a. The Type of Prosthetic Reconstruction.
b. The Occlusal Scheme.
c. The Number, Distribution, Orientation, and Design of
Implants.
d. The Design and Properties of Implant Connectors.
e. Dimensions and Location of Cantilever Extensions.
 Implant success criteria
• Albrektsson et al. (IJOMI 1:11, 1986) proposed the
following minimum success criteria:
1. An individual, unattached implant is immobile when tested clinically.
2. Radiographic examination does not reveal any periimplant
radiolucency.
3. After the first year in function, radiographic vertical bone loss is less than
0.2 mm per annum.
4. The individual implant performance is characterized by an absence of
signs and symptoms such as pain, infections, neuropathies, paresthesia,
or violation of the inferior dental canal.
5. As a minimum, the implant should fulfil the above criteria with a success
rate of 85% at the end of a 5-year observation period and 80% at the
end of a 10-year period.
Indications of implant
therapy
1. Complete or partial edentulism.
2. Inability to wear a removable partial dental
prosthesis or complete denture (e.g. Bone
resorption, pain).
3. Need for long-span fixed dental prosthesis.
4. Unfavorable number and location of potential
natural tooth abutments (e.g posterior edentulism
where FPD is not possible).
5. Single tooth loss that would necessitate preparation
of minimally restored teeth for fixed prosthesis.
6. Orthodontic skeletal anchorage (micro\ mini
implants).
7. Cranio and maxillofacial defects either acquired or
congenital (e.g. obturators, artificial ear or nose).
Indications of implant therapy

Implant supported FPD

Single unit implant restoration • Single implant placement.

Indications of implant therapy

Implant supported complete denture

 Indications of implant therapy

• Implants supported • Implant retained

obturator prosthetic ear
 Contraindications of implant therapy
A. Age:

Underage (delay implant placement

until growth is completed)
B. Medical and Systemic Health–Related Issues:
1. Diabetes (poorly controlled). Relative
2. Bone metabolic disease (e.g., osteoporosis). Relative
3. Radiation therapy (head and neck). Relative/Absolute
4. Bisphosphonate therapy (intravenous). Relative/Absolute
5. Bisphosphonate therapy (oral) . Relative
6. Immunosuppressive medication. Relative
7. Immunocompromising disease (e.g., HIV, AIDS). Relative
8. Bleeding disorders.
9. Severe cardiovascular diseases (Angina, recent MI, high BP).
 Contraindications of implant therapy

C. Psychologic and Mental Conditions:

1. Psychiatric syndromes (e.g., schizophrenia, paranoia). Absolute
2. Mental instability (e.g., neurotic, hysteric). Absolute
3. Mentally impaired; uncooperative. Absolute
4. Irrational fears; phobias. Absolute
5. Unrealistic expectations. Absolute
D. Habits and Behavioral Considerations:
1. Smoking; tobacco use. Relative
2. Parafunctional habits. Relative
3. Substance abuse (e.g., alcohol, drugs).
Relative/Absolute
E. Intraoral Examination Findings:
1. Atrophic jaw bone. Relative
2. Jaw bone or oral mucosa pathology. Relative
3. Periodontal disease. Relative
4. Inability to restore with a prosthesis. Absolute
5. Unrestored teeth and poor oral hygiene.
F. Lack of operator experience.
Advantages of implant therapy
1. Reduces the stress on remaining teeth by offering
independent support and retention.
2. Restore and maintain occlusion and vertical dimension.
3. Preserve natural teeth by avoiding the need to cut down
adjacent teeth for FPD.
4. Preserve bone ( unlike CD or RPD with tissue support).
5. High success rate (above 97% for 10 years).
6. Implant restorations will allow better chewing and clear
speech.
7. Improves stability and retention of CD.
8. Reduces the size of prosthesis in case of CD (eliminate palate
and flanges).
9. Implant restorations have better esthetic.
10. Easy to clean and maintain.
11. Improves psychological health.
 Disadvantages of of implant therapy

1. A surgical procedure is necessary for implant

placement.
2. Need for bone grafting in case of bone
insufficiency.
3. Risk of crown /bridge fracture.
4. High cost.
5. The length of time required from initial dental
implant placement to implant restoration ( in case
of delayed loading).
 Classification of dental implants

• Based on implant placement within the tissues:

1. Endodontic Implant (Stabilizer)
2. Mucosal Inserts.
3. Sub-periosteal implant .
4. Endosteal or Endosseous implant.

a. Plate-form implant.
b. Ramus-frame implant.
c. Root-form implant.
5. Transosseous implant.
 1. 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.
 2. Titanium Mucosal
Insert
These are attachments in dentures to provide
added stability and retention
Intramucousal implants
snap inserts
 3. Sub-periosteal implant
• Subperiosteal Implants were already introduced in
the 1940s.
• These implants are not anchored inside the bone,
but are instead shaped to ride on the residual bony
ridge of either the upper or lower jaw. They are
usually not considered to be osseointegrated
implants.
• Subperiosteal Implants have been used in
completely edentulous as well as partially
edentulous upper and lower jaws. However, the
best results have been achieved in treatment of the
edentulous lower jaw.
 3. Sub-periosteal implant
• Indications:
o Usually a severely resorbed, completely edentulous, lower jaw bone
which does not offer enough bone height to accommodate Root form
Implants as anchoring devices.
 4. Endosteal or Endosseous
implant
• It is a dental implant that extended into
the basal bone for support.
• Only one cortical plate for support.
• They are 3 types:
A. Plate-form implant (Blade vent).
B. Ramus-frame implant.
C. Root form implant.
A. Plate-form implant (Blade vent)

• Their name is derived from their flat, blade-like (or

plate-like) portion, which is the part that gets
embedded into the bone.
• Indications:
o When the residual bone ridge of the jaw is either too thin (due to
resorption) to place conventional Root form Implants or certain vital
anatomical structures prevent conventional implants from being placed.
o Completely edentulous arches where four implants are used.
 B. Ramus-frame implant
• Ramus-frame Implants are designed for the
edentulous lower jaw only and are surgically
inserted into the jaw bone in three different
areas: the left and right ramii and bony
symphysis.
• Indications:
o Severely resorbed, edentulous lower jaw bone, which
does not offer enough bone height to accommodate
Root form Implants. These implants are usually
indicated when the jaws are even resorbed to the
point where Subperiosteal Implants will not suffice
anymore.
o will also stabilize and protect the thin resorbed
mandible from fracturing.
 B. Ramus-frame implant
• The Ramus-frame Implant usually comes in a
standard pre-shaped form and needs to be
custom-fitted to the patient's individual jaw
dimension, as shown below:
B. Ramus-frame implant
 C. Root form implant
• Since the introduction of the Osseointegration
concept and the Titanium Screw by Dr.
Branemark, these implants have become the
most popular implants in the world today.
• Root form Implants come in a variety of shapes,
sizes, and materials and are being offered by
many different companies worldwide.
• Advantages:
1. Adaptability to multiple intraoral location.
2. Uniform precise implant site preparartion.
 C. Root form implant
• Types of root form implants:
o Based on surgical procedure:

1. Two staged.
2. Single staged.
o Based on implant surface:
1. Press-fit/ Non-threaded/Smooth.
2. Screw type/Threaded.
3. Hollow basket implant.
C. Root form implant
C. Root form implant
 5. Transosseous implant
• These implants are not in use that much any more,
because they necessitate an extraoral surgical
approach to their placement, which again
translates into general anesthesia, hospitalization
and higher cost, but not necessarily higher benefits
to the patient.
• In any case, these implants are used in mandibles
only and are secured at the lower border of the
chin via bone plates. These were originally designed
to have a secure implant system, even for very
resorbed lower jaws.
• Indicated in atrophic anterior mandible where root
form implants compromises the strength of the jaw.
 5. Transosseous implant
• The plate on the bottom is firmly
pressed against the lower border
of the mandible anteriorly,
whereas the long screw 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.
5. Transosseous implant
Implant stability