Implantation

Introduction To Dental Implant

Definition

Materials used for dental implant.

Types of dental implant

Osseointegration

Biomechanics of osseointegrated
implant.

Oral Implant:
A device or inert substance, biologic or
alloplastic, that is surgically inserted into soft or
hard tissues, to be used for functional or
cosmetic purposes.

Oral Implant:
A permucosal device which is biocompatible and
biofunctional and is placed within mucosa or, on
or within the bone associated with the oral cavity
to provide support for fixed or removable
prosthetics.

Introduction

Losing tooth/teeth is not new problem

It is possible to replace teeth that look &
function like natural teeth
Implants is one of the means of achieving this
through osseointegration (biological adhesion
of bone tissue & titanium)
Pioneered by prof. Per-Ingvar Branemark in
1952 ( Swedish orthopedics' surgeon)

Examples

Examples

Examples

Advantages & disadvantages of implant over

conventional treatment

Implants do not involve preparation of the

adjacent teeth, they preserve the residual
bone, and excellent aesthetics can be
achieved.
However, it is expensive, the patient
requires surgery, time consuming, and
technically complex.

Types of dental implants

1. Mucosal Insert
2. Endodontic Implant (Stabilizer)
3. Sub-periosteal implant
4. Endosteal or Endosseous implant
Plate-form implant
Ramus-frame implant
Root-form implant
5. Transosseous implant

Root Form Implants

In this presentation we will focus on the Root
Form Implants.

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. Some clinicians
regard them to be the Standard of Care in Oral
Implantology.
These implants can be placed wherever a tooth
or several teeth are missing, when enough bone is
available to accommodate them. However, even if
the bone volume is not sufficient to place Root
form Implants, Bone grafting procedures within
reasonable limits should be initiated, in order to
benefit from these implants.

Root form implant shape:

Other variations dwell on the shape of the
Root form implant. Some are screwshaped, others are cylindrical, or even
cone-shaped or any combination thereof.

Today, the most accepted material for dental implants is high

grade Titaniumeither CP Titanium or an alloy thereof. The
titanium alloy implants tend to be stronger than the CP
titanium implants. The bone integration shows no difference
to the two different types of titanium.

Some implants have an outer coating of Hydroxyapatite

(HA). Other implants have their surface altered through
plasma spraying, or beading process. This was developed to
increase the surface area of the titanium implant and, thus, in
theory, give them more stability. These surface treatments
were also offered as an alternative to the HA coatings, which
on some implants have shown to break loose or even dissolve
after a few years.

Osseointegration
A time-dependant healing process where by
clinically symptomatic rigid fixation of
alloplastic materials is achieved, and
maintained, in bone during functional
loading. (Zarb & Albrektson,1991)

Factors affecting osseointegration

Implant biocompatibility
Implant design
Implant surface
Implant bed
Surgical technique
Loading condition

Bone Quality

According to Lekholm and Zarb.,1985

Quality I
Was composed of homogenous compact bone, usually found in the
anterior lower jaw.
Quality II
Had a thick layer of cortical bone surrounding dense trabecular bone,
usually found in the posterior lower jaw.
Quality III
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.
Quality IV
Had a very thin layer of cortical bone surrounding a core of lowdensity 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.

Surgical technique
Minimal tissue violence at surgery is essential
for proper osseointegration.
Careful cooling while surgical drilling is performed at
low rotatory rates.
Use of sharp drills.
Use of graded series of drills.
Proper drill geometry is important, as intermittent
drilling.
The insertion torque should be of a moderate level
because strong insertion torques may result in
stress concentrations around the implant, with
subsequent bone resorption.

Loading condition
Delayed loading:

A tow-stage surgical protocol

One-stage surgical protocol

Immediate loading:

Immediate occlusal loading (placed within 48 hours

postsurgery)

Immediate non-occlusal Loading (in single-tooth or shortspan applications)

Early loading (prosthetic function within two months)

Biomechanics of osseointegrated
implant
In all incidences of clinical loading, occlusal forces are first
introduced to the prosthesis and then reach the bone implant
interface via the implant. So far, many researchers have,
therefore, focused on each of these steps of force transfer to
gain insight into the biomechanical effect of several factors
such as

Force directions and magnitudes,

Prosthesis type,
Prosthesis material,
Implant design,
Number and distribution of supporting implants,
Bone density, and
The mechanical properties of the bone-implant interface.

Dental Implant Treatment Planning and

Types of Dental Implants
How many teeth are missing?
What is the degree of bone loss?
Are the remaining teeth in a good position and do
they have a long-term prognosis?
What does the patient expect for an end result?
What treatment will result in the best cosmetic
outcome?
What is the patient's budget?

Overall
What is the most practical and feasible
implant treatment that will produce optimal
chewing function and optimal cosmetic
results in a timely and affordable manner?

Diagnosis and
Treatment Planning
The evaluation of a patient as a suitable candidate for
implants should follow the same basic format as the
standard patient evaluation, although some areas
require additional emphasis and attention:
Medical History.
Psychological Status.
Dental History.

Diagnostic phase
Problem list & treatment considerations

radiographic analysis
surgical analysis
esthetic analysis

The superstructure for completely edentulous patients

can be classified as follows:

Implant retained removable overdenture

Implant supported removable overdenture
Fixed detachable prosthesis (Hybrid prosthesis)
Implant supported Fixed Bridge
1) Screwed-in Fixed Bridge
2) Cemented Fixed Bridge

Treatment Plan Selection

Treatment planning and the decision-making
process is a balance between the patients
preferences, finances and clinical factors.
Understanding that cost is an initial barrier to case
acceptance, a large percentage of patients may
reject more expensive options that only include
fixed prostheses.

Treatment Planning Determinants

1. Changes in Oral Structures in Edentulism
2. Posterior Ridge Anatomy
3. Occlusal Forces
4. Quality, Location and Quantity of Bone
5. Implant Size
6. Implant Location
7. Arch configuration
8. "Mapping" the Mandible
9. Cantilevering

1. Changes in Oral Structures in

Edentulism
With successive denture treatments, it is
common for the vertical dimension of occlusion to
decrease as bone resorbs. This promotes an
increased tendency toward a skeletal Class III
relationship.

2. Posterior Ridge Anatomy

Posteriorly, poor ridge height, inadequate
attached gingiva and compromised ridge
shape
cause
increased
horizontal
movement of the prosthesis. This increases
the lateral forces that are brought to bear
on the anterior implants, and will affect bar
and prosthesis design.

3. Occlusal Forces
The maximum bite force of subjects with a
mandibular denture supported by implants is 60 to
200% higher than that of subjects with a conventional
denture
Edentulous patients that are predisposed to
clenching and bruxing may be given the necessary
"tools" to begin parafunctional habits once the implant
bar is secured in place.

4. Quality, Location and Quantity of Bone

The minimum buccal-lingual thickness of osseous tissue
required to successfully place an implant is 5 mm.
In order to achieve a 5.0 mm "flat" base, either the
anterior ridge crest peak must be removed or a bone graft
must be considered.

5. Implant Size
The greater the surface area of the implant-bone system,
the less concentrated the force transmitted to the crest of
bone at the implant interface. Similarly, the greater the
surface area of the implant-bone system, the better the
prognosis for the implant.
For each 0.25 mm increase in diameter, the surface area
of a cylinder increases by more than 10 per cent;
For each 3.0 mm increase in length , the surface area of
a cylinder increases by more than 10 per cent.

6. Implant Location

Ideally, occlusal forces should be directed along

the long axis of the implants. Therefore ,The
angle of the osseous ridge crest is a key
determinant of implant angulation.
the distance between an implant and any
adjacent "landmark" (natural tooth or another
implant), which should be not less than 2.0 mm.

7. Arch configuration
Mandibular arch forms may be classified as tapered or
square.

With tapered arch forms, the most posterior right and left
implants in a four-implant treatment are often placed well
around the "turn" of the arch, creating a "U" shaped
design that is well suited to cantilevering,
With a square arch, the four implants are usually placed in
a relatively straight line. This "straight line" bar design is
not well suited to cantilevering.

8. "Mapping" the Mandible

The anterior symphysis can be divided into five geographic
sites:
A point, 6.0 mm anterior to each mental foramen, determines
the most posterior boundaries, right and left.
Another possible implant location occurs at the midline.
Two additional sites are chosen on each side of the midline,
spaced equidistantly between the midline and the
respective distal sites.

9. Cantilevering

The number of implants, their respective lengths

and locations, the quality of bone support, the
posterior ridge anatomy, occlusal forces, and the
opposing dentition are of greater importance in
determining the appropriate cantilever than a
suggested formula.
One method is to draw a line through the most
anterior implant, and another through the two
most posterior implants. The distance between
the two lines can then be measured. A suggested
maximum cantilever would be 1.5 times this
distance.

Treatment Planning
When all the diagnostic information has been assembled, a
variety of available treatment options must be assessed:
1. One-Implant Overdenture
2. Two-Implant Overdenture
3. Three-Implant Overdenture
4. Four-Implant Overdenture
5. Five-Implant Overdenture

Outline

Why are dentists moving to dental implants ?

Successful dental implant.

Indications for dental implants.

Cont

Advantages of dental implants:

Preservation of tooth structure.

Preservation of bone.

Provision of additional support.

Retrievability.

Resistance to disease.

Increased confidence.

Improves aesthetics, function and speech.

Conclusions

References.

Why are dentists moving to dental

implants ?
1.

2.
3.

Address patients needs

and requests.
High success rate.
Progressive development
of new implant systems,
Diagnostic procedures,
and the introduction of
novel surgical
techniques.

Cont
1.

2.

3.

Advancement of technical
procedures (CADCAM).
Many training courses are
offered by universities,
professional societies and
implant manufacturers.
Profitable.

Successful implant

Successful Osseointegration.

Successful implant

Restoration of normal contour, aesthetic,

function and speech.

Successful implant

Clinically:

Immobile.

No persistent pain, infections, paresthesia or

neuropathies.

Successful implant

Radio-graphically :

No peri-implant radiolucency.

Vertical bone loss should be less than 0.2 mm

annually following the implants first year of
service.

Indications for dental implants.

1.
2.

3.

4.

Intolerance to removable dental prosthesis.

Need for long span fixed prosthesis with
questionable prognosis.
Single tooth loss that will make it necessary to
prepare sound adjacent teeth for a fixed prosthesis.
Unfavourable condition, location and number of
abutment teeth.

Advantages of dental implants

1. Preservation of tooth structure.

Fixed bridge

Implant

Cont
Fixed partial dentures

Single tooth implants

Significant reduction in no need for preparation

the amount of tooth
of adjacent teeth.
structure is necessary
Long term survival:
96.5% at 11 yrs
long term survival:
87% at 10 yrs, 69% at 15 yrs
More expensive
Less expensive

Advantages of dental implants

1.

Preservation of bone.

loss of teeth
Lack of stimulation to the residual bone
Decrease in bone density, height and width.

Bone resorption after extraction

Bone resorption in edentulous

patients

Most of the bone loss occurs in the first year after

extraction.

Continued bone loss for more than twenty years.

Four fold greater in mandible than in maxilla.

Cont

Upwards and medially in maxilla, downwards

and laterally in mandible.

Cont

Teeth stimulate bone maintain bone.

Implants stimulate bone maintain bone.

Complete and partial dentures dont

stimulate bone
Bone resorption, acceleration of bone
resorption if ill fitting

1.

Decreases the surface area available for prosthesis

support.

2.

Eliminates favourable anatomy for retention.

3.

Results in unfavourable denture bearing areas.

Cont

Always inform your patient of the anatomical

consequences of tooth loss.

Always inform your patient of the preventive nature

of dental implants.

Advantages of dental implants

1.

Provision of additional support.

Dentate patient can exert up to 1000 psi of bite

force.

Edentulous patient ( complete denture wearers)

can only exert up to 50 psi of bite force.

Transitioning a patient from complete denture to

an implant supported prosthesis will result in a
dramatic increase in bite force.

Cont

Tooth and mucosa borne dentures :

Cant re-establish posterior support.

Why ?

Advantages of dental implants

1.

Retrievability : reservicing, replacement and

salvaging of the restoration.

Advantages of dental implants

1.

Resistance to disease.
Implants are resistant to caries, natural teeth
are not.

Cont

Consider extraction of teeth and place

implants if :

The patient has poor manual dexterity, and

hence cant maintain good oral hygiene.

The patient has Xerostomia due to

medications (root surface caries).

Advantages of dental implants

1.

Increased confidence.

Improved aesthetics, function and speech.

Conclusions

Single tooth implant is the most predictable and

conservative method of tooth replacement.

Use of removable prosthesis will not allow patient to

recover normal function, aesthetics, speech and
comfort.

Implant supported prosthesis allow patient to

function with confidence and enjoy better quality of
life.

Amazing implants

Outline

Why are dentists moving to dental implants ?

Successful dental implant.

Indications for dental implants.

Cont

Advantages of dental implants:

Preservation of tooth structure.

Preservation of bone.

Provision of additional support.

Retrievability.

Resistance to disease.

Increased confidence.

Improves aesthetics, function and speech.

Conclusions

References.

Why are dentists moving to dental

implants ?
1.

2.
3.

Address patients needs

and requests.
High success rate.
Progressive development
of new implant systems,
Diagnostic procedures,
and the introduction of
novel surgical
techniques.

Cont
1.

2.

3.

Advancement of technical
procedures (CADCAM).
Many training courses are
offered by universities,
professional societies and
implant manufacturers.
Profitable.

Successful implant

Successful Osseointegration.

Successful implant

Restoration of normal contour, aesthetic,

function and speech.

Successful implant

Clinically:

Immobile.

No persistent pain, infections, paresthesia or

neuropathies.

Successful implant

Radio-graphically :

No peri-implant radiolucency.

Vertical bone loss should be less than 0.2 mm

annually following the implants first year of
service.

Indications for dental implants.

1.
2.

3.

4.

Intolerance to removable dental prosthesis.

Need for long span fixed prosthesis with
questionable prognosis.
Single tooth loss that will make it necessary to
prepare sound adjacent teeth for a fixed prosthesis.
Unfavourable condition, location and number of
abutment teeth.

Advantages of dental implants

1. Preservation of tooth structure.

Fixed bridge

Implant

Cont
Fixed partial dentures

Single tooth implants

Significant reduction in no need for preparation

the amount of tooth
of adjacent teeth.
structure is necessary
Long term survival:
96.5% at 11 yrs
long term survival:
87% at 10 yrs, 69% at 15 yrs
More expensive
Less expensive

Advantages of dental implants

1.

Preservation of bone.

loss of teeth
Lack of stimulation to the residual bone
Decrease in bone density, height and width.

Bone resorption after extraction

Bone resorption in edentulous

patients

Most of the bone loss occurs in the first year after

extraction.

Continued bone loss for more than twenty years.

Four fold greater in mandible than in maxilla.

Cont

Upwards and medially in maxilla, downwards

and laterally in mandible.

Cont

Teeth stimulate bone maintain bone.

Implants stimulate bone maintain bone.

Complete and partial dentures dont

stimulate bone
Bone resorption, acceleration of bone
resorption if ill fitting

1.

Decreases the surface area available for prosthesis

support.

2.

Eliminates favourable anatomy for retention.

3.

Results in unfavourable denture bearing areas.

Cont

Always inform your patient of the anatomical

consequences of tooth loss.

Always inform your patient of the preventive nature

of dental implants.

Advantages of dental implants

1.

Provision of additional support.

Dentate patient can exert up to 1000 psi of bite

force.

Edentulous patient ( complete denture wearers)

can only exert up to 50 psi of bite force.

Transitioning a patient from complete denture to

an implant supported prosthesis will result in a
dramatic increase in bite force.

Cont

Tooth and mucosa borne dentures :

Cant re-establish posterior support.

Why ?

Advantages of dental implants

1.

Retrievability : reservicing, replacement and

salvaging of the restoration.

Advantages of dental implants

1.

Resistance to disease.
Implants are resistant to caries, natural teeth
are not.

Cont

Consider extraction of teeth and place

implants if :

The patient has poor manual dexterity, and

hence cant maintain good oral hygiene.

The patient has Xerostomia due to

medications (root surface caries).

Advantages of dental implants

1.

Increased confidence.

Improved aesthetics, function and speech.

Conclusions

Single tooth implant is the most predictable and

conservative method of tooth replacement.

Use of removable prosthesis will not allow patient to

recover normal function, aesthetics, speech and
comfort.

Implant supported prosthesis allow patient to

function with confidence and enjoy better quality of
life.

Amazing implants