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 ABOUT THE BOOK:
•The book Is complete, condse, comprehensive and easy to read book on the subjects of perlodontologyand oral

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Essentials Of
PERIODONTICS & ORAL IMPLANTOLOGY
Published by Dr. Syed Wali Peeran and Dr. Karthikeyan Ramalingam @
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Chapter 51 Classification of Dental Implants
CHAPTER

65 Classification of
Dental Implants

Shaesta Begum & Syed Wali Peeran

Chapter Outline:
• Classification of Dental Implants
– Based on penetration into the tissues
– Based on Macroscopic Body Design of the Implant
– Based on implant design or number of surgeries
required
– Based on the surface of the implant
– Implant surface characteristics
– Implant surface texture and roughness
– Implant surface chemical composition
– Implant surface energy and charge
– Based on the implant-abutment interface of the
implant
– Based on the implant materials used
– Based on the type of biologic response
– Based on the material used for implant production
– Based on the length of Implants
– Based on the width of the implant
• Review Questions
– Essay Questions
– Short notes
• Principal references and suggested further reading

The extensive variety of implants available can be classified severe ridge resorption. Examples include Trans-mandibular
in a number of ways. Few such classifications are briefly implants.
explained as follows: Endosteal implants:
Based on penetration into the tissues: They are single implant units that are placed into the
dentoalveolar and or basal bone and that protrudes through
Mucosal implants-Palatal inserts: the mucoperiosteum to bear prosthesis.They are the most
They are also known as intramucosal inserts, implant commonly used dental implants.
buttons or denture enhancing units. It is a non-reactive Blade implants:
metal/ acrylic appliance affixed to the tissue surface of the These were introduced by Linkow and were clinically used
denture. It enhances retentive qualities of the denture. It in 1960-70’s. The mucoperiosteal flap is elevated and the
has a base, cervix and head. implant is inserted into the jawbone. They were tapped
Sub periosteal implants: in place in a narrow trench made with a rotary bur. One
They comprise an open mesh framework designed to fit or severalposts pierces through the mucoperiosteum
over the surface of the bone beneath the periosteum. after suturing of the flaps. After a few weeks of healing,
Transosteal implants: a fixed prosthesis was fabricated by a classic method and
cemented on top of it.They can used in atrophic ridges at
They pass through the bone. It is generally used in cases of
times avoiding bone regeneration.

Periodontics & Oral Implantology 1

 Implantology Section - XI

Pins: flap. After allowing a period of three to six months for

In the classic technique, three diverging pins are inserted. osseointegration, the implant is exposed to the oral cavity
It is done eitherby a trans-gingival approach or reflecting for abutment placement.
a mucoperiosteal flap through holes prepared with spiral
drills. They are connected with cement at the junction of
3 pins to achieve stability. A single tooth replacement is
placed over this setup. It is presently not in use.
Disk implants:
It is seldom used today. This concept was proposed by
Scortecci. A pin with a disk on its head is inserted laterally
into the jawbone. After insertion into the bone, this
implant had a good retention against extraction forces.
Root form:
It consists of cylindrical implants.
♦ Hollow type Fig. 65.1 Implant fixture
♦ Full type Non-submerged / One-stage implant:
Endodontic implant/endodontic stabilizers: The implant has a collar that extends through the tissues.
They are implants extending through the root canal into the There is no need for a second surgery.
periapical bone.They aid in retention and increase support.
They have good prognosis but are not commonly used.
Based on Macroscopic Body Design of the
Implant:
a. Cylindrical. (Hollow; Straumann –ITI, full; Kirsch-
IMZ): They are either pushed or gently knocked into
place.
b. Screw-shaped (tapered) implants: They are either
self-tapped into the prepared dental implant siteor
inserted following tapping of the bone with a screw
tap.
c. Blade form (Linkow)
d. Pins.
e. Endodontic stabilizers.
Based on implant design or number of
surgeries required:
a. Submerged / Two-stage implant
Fig. 65.2 Single piece Implant
b. Non-submerged / one stage
Submerged /Two stages: Based on the surface of the implant:
The implant is placed in two steps. Initially, an implant is a. Smooth surface
placed within the bone and covered by the mucoperiosteal
b. Machined surface
2 Periodontics & Oral Implantology
Chapter 65
c. Textured surface
d. Coated surface
Implant surface characteristics:
It refers to the micro-design or the micro-topography of the
implant surface. This has been shown to positively influence
the healing process by adsorption of vital biomolecules which
promote cellular migration and attachment.
Surface characteristics also aid in retention of clot and providing
a migratory pathway for differentiating osteogenic cells to reach
the implant surface and hence it is one of the key factors for
successful osseointegration.
There can be modifications in
♦ Topographic properties such as implant surface
texture & roughness
♦ Physical properties such as implant surface energy
and charge
♦ Physiochemical properties such as implant surface
chemical composition.
Fig 65.3 Implant surface roughness and dental
plaque (Teughels et al)
Implant surface texture and roughness :
It is achieved primarily by two main processes
♦ Additive processes
♦ Subtraction processes
Additive processes
Additive process modifies the microstructure and chemical
nature of the implant surface by adding materials or
chemicals to the existing surface such as
♦ Inorganic mineral coatings: Hydroxyapatite
coatings, Plasma sprayed hydroxyapatite coatings, a
Periodontics & Oral Implantology
Classification of Dental Implants
combination of Hydroxyapatite α and β-tricalcium
phosphate (Bonelike®) are the various inorganic
mineral coatings.
♦ Plasma spraying with different powder particles like
titanium oxide, calcium phosphate, hydroxyapatite.
The disadvantages of this technique include,
** Loss of adhesion between the coating and the
substrate material on the long term.
** Thickness of the deposited layer is not uniform.
** The coating is not identical in composition.
♦ Bio-coating with growth factors
♦ Fluoride: On treatment with fluoride solution
Titanium forms soluble TiF4 species. It creates surface
roughness and fluoride incorporation favorable to
the osseointegration of dental implants
♦ Addition of material such as hydroxyapatite, calcium
phosphates, sulphates or carbonates and laminin-1
has all been used.
♦ Anodization: It is an electrochemical addition of a
titanium oxide layer. It roughens the implant surface.
♦ Doped surface.
♦ Nanosized hydroxyapatite-coated surfaces.
Note: Osteogenic coatings -placement of a thin film of
organic and inorganic osteoinductive and osteoproliferative
materials on implant surfaces.(Ghanem et al)
♦ Rationale: Augment bone-to-implant contact (BIC) in
osteoporotic bone.
♦ Experimental studies have shown that osteogenic
coatings are effective in enhancing BIC,However
their clinical relevance requires further investigations.
(Ghanem et al)
Subtraction processes
Subtraction processes modifies the microstructure and
chemical nature of the implant surface by removing or
altering the existing surfaces. This is achieved by
♦ Machining: e.g., Laser micro-machining technique.
♦ Etching: Etching with strong acids. e.g. Sulfuric
acid and hydrochloric acid.
♦ Etching and anodization.
3
 Implantology Section - XI

♦ Blasting (Grit blasting, Sand blasting): Surface liquid is drawn near the surface or beading of the drop if
roughness depends on the particle used. repelled.
♦ Combination of these processes The surface energy characteristics may be altered by
addition of Fibronectin and grooves.
Implant surface chemical composition:
Based on the implant-abutment interface of
It is important for adsorption of proteins and attachment
of cells onto the implant surface. the implant:
Dental implants are generally made of commercially pure a. External hex
titanium or titanium alloys. b. Internal hex
The degrees of purity are graded from 1 to 4 which is The characteristic variation is in the coronal surface of the
characterized by oxygen, carbon and iron content. Most implant.The two types can be distinguished by the presence
dental implants are made from grade 4 cpTi as it is stronger or absence of this geometric feature on the interface. This
than other grades. The surface chemical composition of geometry is further described as,
titanium implants also affects the hydrophilicity of the
surface. Highly hydrophilic surfaces seem more desirable ♦ octagonal.
than hydrophobic ones given their interactions with ♦ hexagonal.
biological fluids, cells and tissues. ♦ cone screw.
Titanium is highly reactive metal and forms titanium ♦ cone hex.
dioxide on its surface within seconds and grows over years
♦ cylinder hex.
when it faces biological fluids. Titanium oxides have higher
di-electric constants than other metal oxides and tend to ♦ spline.
adsorb biomolecules from blood during implant insertion. ♦ cam.
Initial attraction is by weak Vander Waals forces. However,
♦ cam tube, and
due to high dielectric constant and high polarizability of
the molecules after adsorption, it will lead to high bond ♦ Pin/slot.
strength which becomes irreversible after 30kcal/mol. The connection can be categorized as,
Implant surface energy and charge: ♦ A slip-fit joint - a slight space exists between the
mating parts, and a passive connection
The free surface energy called wettability is an important
♦ A friction-fit joint -no space exists between the
parameter for the initial interactions which is responsible
mating components and the parts are accurately
for the formation of a pellicle layer.
forced together.
The surface wettability of implants determines the biological ♦ The joining surfaces are further characterized as
cascade of events at the implant/host interface. being
Sessile drop technique measures the wetting characteristics ♦ A butt joint with contact between 2 right-angle flat
of a known solid material. A drop of the chosen wetting surfaces
liquid is placed on the specimen surface. The angle formed
between the tangent of the drop at the solid or liquid or ♦ A bevel joint with angled surfaces - either internally
gas three-phase boundaryand the horizontal baseline of or externally
the solid surface is recorded. This contact angle (CA or h) The joined surfaces may also incorporate a rotational
gives the wettability of the chosen liquid. resistance, indexing feature or lateral stabilizing geometry.
If water is used as the wetting agent, CA denotes the
hydrophilic nature of the metal surface. If CA varies from
0 to 180, it denotes the spreading of the drop when the
4 Periodontics & Oral Implantology
Chapter 65 Classification of Dental Implants

However, a large proportion of them have surface

modifications which are discussed under Implant surface
characteristics.
Based on the type of biologic response:
It is based on the response created after implantation and
the host tissue reaction in long-term to the implant. The
three major types of biodynamic activity are,
a. Biotolerant
b. Bioinert
c. Bioactive
Fig 65.4 : Parts of dental implant Biotolerant materials are those that are not necessarily
rejected when implanted into living tissue, but are
Based on the implant materials used: surrounded by a fibrous layer in the form of a capsule.
(Sykaras et al)
The materials used for fabrication of dental implants can
be divided in two ways: Bioinert materials allow close apposition of bone on their
surface, leading to contact osteogenesis. (Sykaras et al)
Based on chemical point of view; they are of three main
Bioactive materials also allow the formation of
groups
new bone onto their surface, but ion exchange with host
a. Metallic implants: Titanium, stainless steel, chromium tissue leads to the formation of a chemical bond
cobalt. along the interface (bonding osteogenesis). (Sykaras et
b. Ceramics. al)
c. Polymers. Bioinert and bioactive materials are also
d. Miscellaneous: Carbon compound called osteoconductive, meaning that they can act as
scaffolds allowing bone growth on their surfaces.
Table 65.1: Classification of dental implant materials (Sykaras et al)
Biodynamic Chemical composition
activity Metals Ceramics Polymers
Biotolerant Gold Polyethylene
Cobalt-chromium alloys Polyamide
Stainless steel
Polymethylmethacrylate
Zirconium
Niobium Polytetrafluroethylene
Tantalum Polyurethane
Commercially pure titanium Aluminium oxide
Bio-inert Zirconium oxide
Titanium alloy (Ti-6Al-4V) Poly-ether-ether-ketone
Hydroxyapatite
Tricalcium phosphate
Tetracalcium phosphate
Calcium pyrophosphate
Bioactive
Fluorapatite
Brushite
Carbon-silicon
Bioglass

Periodontics & Oral Implantology 5

 Implantology
Many of the metals and alloys like gold, stainless steel, and
cobalt-chromium are now obsolete within the oral implant
industry due to lower long-term success and adverse
reactions. Some of the recent studies have also questioned
if titanium dioxide is bioinert.
Based on the material used for implant
production:
Titanium:
Commercially pure Titanium along with its alloys is widely
used as dental implant material. Titanium is non-toxic and
is corrosion resistant. It’s relatively low modulus, and
good fatigue strength, machinability and formability also
permit its use as a dental implant.
Fig. 65.5 Titanium as dental implant material
Fig. 65.6 Drawbacks of Titanium dental implants (Anderiotelli et al. & Noronha Oliveira et al.)
6 Periodontics & Oral Implantology
Section - XI
Titanium alloys:
To the pure titanium traces of other elements such
as nitrogen, carbon, hydrogen, and iron have also been
added for stability or improvement of the mechanical and
physicochemical properties. Iron is added for corrosion
resistance and aluminium is added for increased strength
and decreased density, while vanadium acts as an aluminium
scavenger to prevent corrosion.The most common alloy
include Titanium– 6 aluminium–4 vanadium (Ti-6Al-4V)
Titanium alloys are mainly composed of Ti6Al4V (grade
5 titanium alloy) with greater yield strength and fatigue
properties than pure titanium. Titanium and its alloys
(mainly Ti-6Al-4V) have become the metals of choice for
endosseous parts of dental implants due to the following
features:
♦ On exposure to air, an oxide layer forms almost
instantaneously on the titanium surface. It reaches a
thickness of 2 -10nm and provides resistance against
corrosion. This feature is called passivation.
♦ Titanium also interacts with the biologic fluids with
this oxide layer. This is responsible for the excellent
biocompatibility.
♦ It has low modulus of elasticity and tensile strength
when compared to most other alloys.
Chapter 65 Classification of Dental Implants

Tantalum: implants and newer techniques such as Powder

injection molding (PIM), also called ceramic injection
In 1802 Anders Gustaf Ekeberg a Swedish chemist and
molding has lead to Zircona implants with better
mineralogist discovered Tantalum element. in 1802.
properties.
Tantalum is a rare, hard, blue-gray, lustrous transition metal
with high corrosion resistance. It belongs to the refractory A recent review by Hafezeqoran and Koodaryan
metal group, which includes titanium, hafnium, niobium and showed that the direct bone to implant contact(BIC)
rhenium. was better for acid etched zirconia implants compared
with those of titanium implants. Whereas Unmodified
“Trabecular metal” or porous tantalum bears an zirconia implants showed favorable BIC values compared
interconnected porous structure, which is similar to to modified-surface zirconia implants
human cancellous bone. It is comprised of approximately
99% tantalum and 1% impurities by weight. It optimizes
the mechanical properties and reduces the high costs of
purification and fabrication of tantalum. Hence as the porous
tantalum has a similar structure and allows for the in growth
of bone tissue it is recently used in implant dentistry.
Ceramics:
Ceramics are inorganic, non-metallic materials
manufactured by compacting and sintering at elevated
temperatures. These materials are bio-inert in nature or
bioactive forming a cohesive chemical bond with bone.
Widely used bioactive ceramics include Hydroxyapatite
(Ca10 (PO4)6(OH) 2) (HA), tricalcium phosphate (Ca3 Fig. 65.7 Zirconia implant
(PO4)2), and bio-glasses
High-strength ceramics from aluminium and zirconium
oxides have been used.
Zirconia:
Zirconium is a metal with its name originating in Arabic
“Zargun” which means golden in colour. Zirconia is
zirconium oxide. It has been an upcoming bio-ceramic
due to its wide range of properties such as inertness to
biodegradation, high strength, and physical characteristics
such as white colour, ability to transmit light, minimal
Fig. 65.8 Zirconia-Dental implant material
thermal and electrical conductivity.
Polymers:
It is indicated in aesthetic zones especially anterior A variety of polymers, including ultrahigh molecular
restorations with thin gingival biotype as it presents a weight polyurethane, polyamide fibres, poly methyl
less noticeable transition compared to metal framework methacrylate resin, polytetrafluoroethylene, and
substructure.The limitations include low fracture toughness polyurethane, are used as materials for dental implants.
or inherent brittleness They had lower elastic moduli with magnitudes closer to
Stabilized zirconia such asYttria-stabilized Zirconia (Y–TZP) soft tissues and hence were used to mimic the micro-
ceramics present excellent mechanical and tribological movement of the periodontal ligament and possibly allow
properties together with biocompatibility and are correctly connection with natural teeth.
regarded as a good choice for preparing dental implants. However, due to other inferior mechanical properties such
Hot isostatic press (HIP) used for preparing Zirconia dental as low creep, low fatigue strength, absence of adhesion to
Periodontics & Oral Implantology 7
 Implantology
tissues and altered immunologic reactions limit their field
of applications.
Today, polymeric materials are generally limited to
the manufacturing of shock-absorbing components
incorporated into the supra-structures, as internal force
distribution connectors for osseointegrated implants.
Poly-ether-ether-ketone (PEEK):
It is a promising high-performance polymer.
♦ It is a semi-crystalline thermoplastic polymer.
♦ It is bio-inert material and has no osteoconductive
properties.
♦ It has a very good strength and stiffness.
♦ It has an outstanding thermal and chemical
resistance.
♦ It is colorless.
♦ It has an elastic modulus similar to that of the human
cortical bone.
♦ It uses in spinal surgery has shown it to have high
biocompatibility with no evidence of cytotoxicity,
mutagenicity, carcinogenicity, and immunogenicity.
However, the results cannot be extrapolated to its
use as dental implants.
♦ Its long-term osseointegration results are unknown.
It is currently investigated in-vivo and in-vitro.
♦ Bioactive Nanoparticles such as Titanium oxide,
Fluorohydroxyapatite and Hydroxyapatite particles
can be combined with PEEK to produce bioactive
peek nanocomposites which may have better
osteoconductive properties. Bioactive PEEK Based on the width of the implant:
nanocomposite implants and various other surface
modifications of PEEk are currently studied in vitro. ♦ Narrow diameter Implants: diameters ≤3.75 mm
Newer biomaterials:
Ni-free Ti-based BMG alloys:
Glass–ceramics such as Wollastonite–cristobalite. They
are polycrystalline materials with an inorganic–inorganic
microstructure that are prepared from base glass by
controlled crystallization.
8 Periodontics & Oral Implantology
Section - XI
Based on the length of Implants:
Short Implants:
Short implants (≥10 mm) have been proposed as an
alternative choice for the prosthetic treatment of atrophic
alveolar ridges.Close proximity to the maxillary sinus and
mandibular canal is an ideal situation for placement of short
implants.
Fig. 65.9: Short dental implants
Annibali et al showed that short implants have high
survival rates [99.1% (95%CI: 98.8-99.4)] and low
incidence of biological and biomechanical complications
reported after a mean follow-up period of 3.2 ± 1.7 yrs.
In a recent meta-analysis Monje et al concluded that the
survival rate of short implants (less than 10mm) was not
affected by the length or the width of the implant. A
meta-analysis by Gonçalves et al revealed the short
implants to be a successful treatment option. However,
Lemos et al cautioned the use of shorter than 8 mm
implants in the posterior area as they present greater risk
to failure than the standard implants.
♦ Conventional diameter implants: diameters >3.75
mm but less than 4.5 mm
♦ Wide diameter implants: >5 mm.
♦ In a systematic review, Javed & Romanos concluded
that the long-term survival of implants in posterior
maxilla was secondarily influenced by implant
diameter.
Chapter 65
Review Questions:
Essay Questions:
1. Define dental implant and classify dental implants.
2. Write in detail about Implant surface characteristics.
Short notes:
3. Write a short note on Zircona dental implant
4. What are Poly-ether-ether-ketone (PEEK). What are
its possible applications in dental implantology.
5. What are the advantages and disadvantages of short
dental implants.
Principal references and suggested further
reading:
♦ Abraham CM.A Brief Historical Perspective on Dental
Implants, Their Surface Coatings and Treatments. The
Open Dentistry Journal. 2014; 8:50-55.
♦ Andreiotelli M, WEenz HJ, Khoal RJ. Are ceramic
implants a viable alternative to Titanium implants? A
systematic literature review. Clin Oral Implants Res
2009: 20:32–47
♦ Annibali S, Cristalli MP, Dell’Aquila D, Bignozzi I, La
Monaca G, Pilloni A. Short dental implants: a systematic
review. J Dent Res. 2012 Jan;91(1):25-32.
♦ Binon P; Implants and Components: Entering the New
Millenium:Volume 15, Number 1, 2000: 76-95.
♦ Brunski et al; Biomaterials and Biomechanics of Oral
and Maxillofacial Implants: Current Status and Future
Developments;Volume 15, Number 1, 2000: 15-45.
♦ Charles H.Thorne, Grabb and Smith’s Plastic Surgery,
6th Edition Lippincott Williams & Wilkins, Chapter 7
Page 58-65.
♦ Cionca N, Hashim D, Mombelli A. Zirconia dental
implants: where are we now, and where are we
heading? Periodontol 2000. 2017 Feb;73(1):241-258.
♦ Degidi M, Piattelli A, Iezzi G, Carinci F. Wide-diameter
implants: analysis of clinical outcome of 304 fixtures. J
Periodontol. 2007; 78(1):52-8.
♦ Donley TG, Gillette WB. Titanium endosseous
implant–soft tissue interface: A literature review. J
Periodontol 1991; 62:153–160.
Periodontics & Oral Implantology
Classification of Dental Implants
♦ Duraccio.D, Mussano.F, Faga MG. Biomaterials for
dental implants: current and future trends. Journal of
Materials Science 2015. 50:4: 4779-4812.
♦ Ghanem A, Kellesarian SV, Abduljabbar T, Al-Hamoudi
N, Vohra F, Javed F.Role of Osteogenic Coatings on
Implant Surfaces in Promoting Bone-To-Implant
Contact in Experimental Osteoporosis: A Systematic
Review and Meta-Analysis. Implant Dent. 2017 Jul 31.
doi: 10.1097/ID.0000000000000634.
♦ Gonçalves TM, Bortolini S, Martinolli M, Alfenas BF,
Peruzzo DC, Natali A, Berzaghi A, Garcia RC. Long-
term Short Implants Performance: Systematic Review
and Meta-Analysis of the Essential Assessment
Parameters. Braz Dent J. 2015 Jul-Aug;26(4):325-36.s
♦ Guehennec Le, Soueidan A, Layrolle P, Amouriq Y.
Surface treatments of titanium dental implants for
rapid osseointegration. Dental Materials 2007; 23:
844-854.
♦ Hafezeqoran A, Koodaryan R. Effect of Zirconia Dental
Implant Surfaces on Bone Integration: A Systematic
Review and Meta-Analysis. Biomed Res Int. 2017;
2017:9246721.
♦ Hasan I, Bourauel C, Mundt T, Heinemann F.
Biomechanics and Load Resistance of Short
Dental Implants: A Review of the Literature. ISRN
Dentistry, vol. 2013, Article ID 424592, 5 pages, 2013.
doi:10.1155/2013/424592
♦ Johansson CB, Han CH,Wennerberg A, Albrektsson T.
A quantitative comparison of machined commercially
pure titanium and titanium-aluminum-vanadium
implants in rabbit bone. Int J Oral Maxillofac Implants
1998;13(3):315–321.
♦ L. Bao et al. Preparation and characterization of TiO2
and Si-doped octacalcium phosphate composite
coatings on zirconia ceramics (Y-TZP) for dental
implant applications. Applied Surface Science 2014;
290: 48– 52.
♦ Lemos CA, Alves ML, Okamoto R, Mendonça MR,
Pellizzer EP. Short dental implants versus standard
dental implants placed in the posterior jaws: A
systematic review and meta-analysis. J Dent. 2016
Jan 19. pii: S0300-5712(16)30005-7. doi: 10.1016/j.
jdent.2016.01.005. [Epub ahead of print]
9
Implantology
♦ Liu Y, Bao C,Wismeijer D,Wu G.The physicochemical/
biological properties of porous tantalum and the
potential surface modification techniques to improve
its clinical application in dental implantology. Mater
Sci Eng C Mater Biol Appl. 2015 Apr; 49:323-9.
♦ Meffert RM, Langer B, Fritz ME. Dental implants: A
review. J Periodontol 1992; 63:859–870.
♦ Misch EC, Contemporary implant dentistry: 3rd
Edition, Mosby Elseiver, Chapter 24; page 511-542.
♦ Monje A, Fu JH, Chan HL, Suarez F, Galindo-Moreno
P, Catena A, Wang HL. Do implant length and width
matter for short dental implants (<10 mm)? A meta-
analysis of prospective studies. J Periodontol. 2013
Dec;84(12):1783-91.
♦ Mueller et al. Analysis of the influence of the macro-
and microstructure of dental zirconium implants on
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