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DENTAL IMPLANTS

AN INTRODUCTION

Definition

An endosteal alloplastic
biologically compatible
material surgically
inserted into the
edentulous bony ridge

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Definition
• A 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).

BASIC TERMINOLOGY

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Alternative Solutions
• Partial and Full Dentures

• Crowns

• Bridges

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Use
• to serve as a
foundation for
prosthodontic
restoration

History (endosseous)
• dates to Egyptians
•Greenfield (1913) -
patented two-stage
system
•Formiggini (1947) -
“father of modern
implantology”
helical wire spiral

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History (endosseous)
• single stage
–one-piece from bone through
oral mucosa (crystal sapphire
implants)
• two-stage
–bony implant separate from
transmucosal portion
–variable design & materials

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".

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Before & After

Before & After

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Biomaterials
• most commonly used
–commercially pure (CP)
titanium
–titanium-aluminum-vanadium
alloy (Ti-6Al-4V) - stronger &
used w/ smaller diameter
implants

Titanium
• lightweight
• biocompatible
• corrosion resistant
(dynamic inert oxide layer)
• strong & low-priced

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“Osseointegration”
• Bränemark - late 1980s
direct structural & functional
connection between ordered,
living bone & surface of a
load-carrying implant

“Osseointegration”
• similar soft-tissue
relationship to natural
dentition (sulcular
epithelium)
• hemi-desmosome like
structures connect
epithelium to titanium
surface

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“Osseointegration”
• circumferential and
perpendicular connective
tissue
• no connective tissue insertion
• no intervening Sharpey’s fiber
attachment

“Osseointegration”
• bone-implant interface
–osteoblasts in close proximity
to interface
–separated from implant by thin
amorphous proteoglycan layer
–osseointegration – highly
predictable

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Biocompatibility of Material
Desired Mechanical Surfaces
Properties
• High yield strength • Composition
• Modulus close to • Ion release
that of bone’s
• Built-in margin of • Surface
safety: Changes in modifications
environment
around implant

Replacing a Single Missing

Posterior Tooth

Implant surgically inserted

Permanent implant crown in place

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Components & Terminology

• coping or prosthesis screw
(top)
• coping
• analog
– implant body
– abutment
• transfer coping (indirect or
direct)

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Components & Terminology

• hygiene screw
• abutment
– for screw, cement or attachment
• second stage permucosal
abutment
• first stage cover screw
• implant body or fixture
(bottom)

Types of Implants
• Screw Implants
(Left to Right: TPS screw,
Ledermann screw,
Branemark screw, ITI Bonefit
screw)

• Cylinder Implants
(Left to Right: IMZ, Integral,
Frialit-1 step-cylinder, Frialit-
2 step-cylinder)

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Procedure
• First Surgical Phase (Implant Placement)
Under local anesthetic the dentist places
dental implants into the jaw bone with a very
precise surgical procedure. The implant
remains covered by gum tissue while fusing to
the jaw bone.

Second Surgical Phase (Implant Uncovery)

After approximately six months of healing.
Under local anesthetic, the implant root is
exposed and a healing post is placed over top
of it so that the gum tissue heals around the
post.
Prosthetic Phase (Teeth)
Once the gums have healed, an implant crown
is fabricated and screwed down to the implant.

Advantages
• no preparation of
tooth/adjacent teeth
• bone stabilization &
maintenance
• retrievability
• improvement of function
• psychological improvement

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Disadvantages
• risk of screw loosening
• risk of fixture failure
• length of treatment time
• need for multiple surgeries
• challenging esthetics

Criteria for success

• no peri-implantitis
• no associated radiographic
radiolucency
• marginal bone loss 1.0-
1.5mm first year; then <
0.1mm annually thereafter

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Criteria for success

• tissue integration: bone/soft
tissue “osseointegration”
• absence of mobility
• no progressive soft tissue
changes or bone loss
• stable clinical attachment
level

Criteria for success

• absence of bleeding upon
probing/excessive probing
depths
• absence of discomfort
• success rate varies with
bone quality, loading
dynamics, etc.

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Criteria for success

• anticipated success rate of
+97% anterior mandible; 90%
maxilla;
decreases in posterior
quadrants due to poorer
bone quality (10 yrs)
– best bone: good cortical with
some cancellous for
vascular supply

Problems
• soft tissue reactions
• fractured or
loosened screws
• failing or failed
fixture
• broken attachments/
components

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Problems
• soft tissue reactions
– most common due to loose
screws
– poor oral hygiene can lead
to
“peri-implantitis” - may result
in progressive bone loss
– lack of attached
periabutment soft tissue
– failed or failing implants

Failing implant vs.

Failed implant
• “implantitis” vs. periodontal
disease!
• failing implant
–clinical signs: progressive
crestal bone loss; soft tissue
pocketing; BOP w/ possible
purulence; tenderness to
percussion or torque

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SUCCESS CRITERIA

FIGURE 1
Figure 1 shows an histological section of a
titanium screw threaded implant which has
been in function in bone for 1 year. There
is very close apposition of bone over most
of the implant surface.

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MAINTAINING
OSSEOINTEGRATION
It has been proposed that the biological
process leading to and maintaining
osseointegration, is dependent upon a
number of factors which include:
• Biocompatibility and implant design
• Bone factors
• Loading conditions

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Implant Design
The main design parameters are:
• Implant length
• Implant diameter
• Implant shape
• Surface characteristics

•
Figure 2. Three different designs of endosseous implants
being inserted into prepared sites within the jaw bone.
Scanning electron micrographs of the implants are
shown in Figures 7 to 9. Figure 2a is a machined
threaded implant of the Branemark design (Nobel
Biocare). Figure 2b is an Astra ST implant which has a
microthreaded coronal portion, a macro-threaded apical
portion and the surface has been blasted with titanium
oxide. Figure 2c is an ITI Straumann implant which has a
smooth transmucosal collar, a macro-threaded body and
a plasma sprayed surface.

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Figure 3
• Figure 3. Various forms of implant abutment are
illustrated. Figure 3a shows ball abutments which are
used to support overdentures. Figure 3b shows
abutments which are used to support individual crowns
in 'single tooth restorations'. The crowns are cemented
on the parallel sided hexagon. Figure 3c shows four
conical shaped abutments which are used to support a
bridge superstructure. In this the bridge would be
screwed to the abutments rather than being cemented.
Figure 3d shows some simple cylindrical healing
abutments which are used during the healing phase of
the mucosa before definitive abutments are selected.

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Figure 4
• Figure 4. An implant of the ITI Straumann
type has been inserted and left protruding
through the mucosa in a one stage
surgical procedure. A wide screw has been
placed on the top to protect the inner
aspect of the implant until a definitive
abutment is connected.

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Figure 5
• Figure 5. Exposure of two implants which
have been buried beneath the mucosa for
a period of 6 months. Bone has grown
over the top of them and this needs to be
removed before a healing abutment is
connected.

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Figure 6
• Figure 6. A periapical radiograph of a single
tooth implant. The bone contacts the implant up
to the most coronal thread. An abutment screw
which is more radio-opaque can be seen
connecting the abutment to the implant. The
crown is all porcelain and is cemented to the
abutment. In this system (Branemark) the
landmark for measuring the bone level from is
the junction between implant and abutment.

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Figure 7
• Figure 7. This shows a scanning electron
micrograph of a Branemark/Nobel Biocare
implant. Figure 7a shows the basic thread
design and figure 7b a higher power view
of the machined surface.

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Figure 8
• Figure 8 shows a scanning electron
micrograph of an Astra ST implant. The
conical neck has a microthread and the
apical part a coarser self tapping thread
(fig. 8a). Figure 8b shows a higher power
view of the blasted
(Tio-blast) surface.
.

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Figure 9
• Figure 9 shows a scanning electron
micrograph of an ITI Straumann solid
screw implant. The polished transmucosal
neck is clearly demarcated from the
plasma sprayed body (fig. 9a). The thread
has a coarser pitch than the implants
shown in figures 7 and 8. Figure 9b shows
the plasma sprayed surface at the same
magnification as figure 7b and 8b. The
increase in surface area is considerable.

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Figure 10
• Figure 10 shows examples of dental
panoramic tomograms of edentulous jaws.
Both show extensive resorption of the
maxillary ridge. There is far less resorption
of the mandible in figure 10a than figure
10b. In the latter case there is reasonable
bone volume in the anterior mandible but
resorption close to the level of the inferior
dental canal in the posterior part.

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