DENTAL IMPLANTS

HISTORY
Egyptians shaped seashells and hammered them
directly into the gums for the purpose of replacing
teeth

Ivory and the bones of animals were also sometimes

used to replace missing teeth.
During 1700s lost teeth were often replaced with teeth
from human donors. (immune system reactions).

But the use of the metal alloys came into practice until
1800s when Gold, platinum and other metal alloys
were used experimenally. (long term success rate was
poor)
In 1950s a Swedish professor named Per-Ingvar
Brånemark made the first big stride towards today’s
dental implant procedures (known as oral
implantology).

 In 1951, this orthopedic surgeon came across the

concept quite by accident. Professor Brånemark and
his research team were studying microscopic aspects
of the bones’ healing process in lab.
CLASSIFICATION
Subperiosteal implants : ( below the periosteum) and ON BONE

These implants require placing the implants on and around the

bone rather than in it.

This type of implant consists of a non osteointegrated framework

that rests on the surface bone of mandible and maxilla.

The framework is positioned beneath the mucosa with, typically,

a number of posts penetrating the mucosa to support an
overdenture.
These are complete, unilateral and circumferential
implants. In 1943, Dahl of Sweden placed the
subperiosteal implant with four projecting posts.

 Direct bone impression is made for the “on bone”

implants n then the cobalt-chrome-molybdenum
casting is done to retrieve the subperiosteal implants
or CT generated CAD CAM model can be used.
The problems encountered with the implant systems
are infection, exteriorisation by the downgrowth of
epithelium and damage to the underlying bone.
Transostealimplants (trans ‘through’
and osteum ‘bone’)

 These implants are limited to ANTERIOR

mandibular bone only.

 And are also known as staple bone implants,

mandibular staple implants and transmandibular
implants (1989 Basker).
These combine the subperisoteal and endosteal
components and penetrates both cortical plates.
 Endosteal implants : ( in
bone)
Its a device which is placed into the alveolar bone
and / or basal bone of the mandible or maxilla and
transect only one cortical plate

In 1978 a two-stage threaded titanium root form

implant was 1st presented in north America by
Branemark and was termed as ‘fixture’ and the
fixture was placed in 1965.
 These are of :
Ramus frame implants : these are horse shoe
shaped stainless steel device inserted into the
mandible from one retromolar pad to the other
and passes through the anterior symphysis area

Blade implants : it consists of thin plates in the

form of blade embedded into the bone

Root form implants : designed to mimic the

shape of the root of a tooth and helps in
directional load distribution.
Root form blade or plate form

 form

Ramus forms
CLASSIFICATION BASED ON THE IMPLANT MATERIAL

METALLIC IMPLANT
Most popular material in use today is TITANIUM.
Other metallic implants are stainless steel, cobalt
chromium, molybdenum alloy vitallium

CERAMIC & CERAMIC COATED IMPLANTS

These materials are also used to coat metallic
implants. These ceramics can either be plasma sprayed
or coated to produce bio active surface. Non reactive
ceramic materials are also present
POLYMERIC IMPLANT
In the form of polymethyl methacrylate &
polytetrafluoroethylene. Have only been used as
adjuncts stress distribution along with implants rather
than used as implants by themselves

CARBON IMPLANTS
Made up of carbon with stainless steel. Modulus of
elasticity equivalent to bone and dentine. Brittleness
leads to fracture
CLASSIFICATION BASED ON
ATTACHMENT MECHANISM OF THE
IMPLANT

FIBROINTEGRATION :
Proposed by Dr.Charles Wiess. Complete
encapsulation of the implant with soft tissues. Soft
tissue interface could resemble the highly vascular
periodontal fibers of natural dentition

 OSSEO-INTEGRATION:
Direct contact between the bone and the surface of
the loaded implant .Described by BRANEMARK. Bio
active material that stimulate the formation of bone can
also be used
 DENTAL IMPLANT
A prosthetic device made of alloplastic material (s)
implanted into the oral tissues beneath the mucosal
or/ and periosteal layer, and on/or within the bone to
provide retention and support for a fixed or
removable dental prosthesis

A substance that is placed into or/and upon the jaw

bone to support a fixed or removable dental
prosthesis
 IMPLANT COMPONENTS
Fixture
Abutment
Prosthesis
 FIXTURE
Actually engages the bone.
Depending upon the implant systems the various
surfcaces of fixtures are:
 Threaded
 Grooved
 Perforated
 Plasma sprayed or coated
 Abutment
It is the connection between the implant fixture and
the prosthesis that is to be fabricated.

Usually connected to the fixture by means of a SCREW

or can be CEMENTED.
 Prosthesis
Can be attached to the abutments through the use of
 Screws
 Cement
 Precision attachments
 Placement and Restoration
FIRST STAGE
Surgical Part where the implant is placed into the bone.
Implant left alone for a period of 4 to 6 months
depending upon the bone equality
Allowed to heal
Become osseointegrated.
SECOND STAGE
Implant is exposed through oral environment with a
healing cap to ensure proper healing of soft tissues
around the site of the future abutment.
The RESTORATIVE PHASE then follows with the
placement of abutments and either a fixed partial
denture or a removable denture.
“CONCEPT OF OSSEOINTEGRATION”

Dr. Per-Ingvar Branemark

Orthopaedic surgeon
Professor University of Goteburg, Sweden.
Threaded implant design made up of pure titanium.
 Definitions
“The apparent direct attachment or connection of osseous
tissue to an inert, alloplastic material without intervening
connective tissue”.
- GPT 8
Structurally oriented definition :
“Direct structural and functional connection between the
ordered, living bone and the surface of a load carrying
implants”.
- Branemark and associates (1977)
Histologically :
Direct anchorage of an implant by the formation of bone
directly on the surface of an implant without any
intervening layer of fibrous tissue.
- Albrektson and Johnson (2001)
 FIBROINTEGRATION OSSEOINTEGRATION

Vs

Concept of soft tissue Concept of Bony

anchorage Anchorage
Linkow (1970), James (1975), Branemark (1969)
Weiss (1986).
 “ Fibrous integration as tissue to implant contact with
interposition of healthy dense collagenous tissue between the
implant and bone”.
 “Direct bone to implant interface without any intervening
layer of fibrous tissue”.
 IMPLANT
DESIGN
CHARACTERISTIC
Implant Design characteristics :
Implant design refers to the three dimensional structure of the
implant.
Form, shape, configuration, geometry, surface macrostructure,
macro irregularities.
Cylindrical Screw shaped implants.
Threaded Non threaded
 Advantages of threaded implants

 More functional area for stress load distribution than

the cylindrical implants.

 Threads improves the primary implant stability avoids

micro movement of the implants till osseointegration
is achieved.
 Non threaded Threaded

Tendency for slippage  No slippage tendency

Bonding is required  No bonding is required
IMPLANT SURFACE
CHARACTERISTIC
 Implant
surface
characteristics
Different machining process results in different surface topographies

1) Turned surface/ machined surface

2) Acid etch surface - HCl and H2SO4

3) Blasted surface – TiO2 / Al2O3 particles
4) Blasted + Acid etch surface
- Al2O3 particles & HCl and H2SO4
- Tricalcium phosphate & HF
5) Hydroxy apatite coated surface (HA)

6) Titanium plasma sprayed surface (TPS)

7) Oxidized surface
8) Nanosized hydroxyapatite coated surfaces
Additive surface treatment :

Titanium plasma spraying (TPS) hydroxyapatite (HA) coating

Substractive surface treatment :

Blasting with titanium oxide / aluminum oxide and acid etching

Modified surface treatment :

Oxidized surface treatment

Laser treatment

Ion implantation
Machined / turned surfaces : gold standard.
Moderately rough implant surfaces : For faster & firmer bone integration
• Roughness parameter (Sa) 0
0.04 –0.4 m - smooth
0.5 – 1.0 m – minimally rough
1.0 –2.0 m – moderately rough
> 2.0 m – rough
Advantages of moderately rough surface :
Faster osseointegration, retention of the fibrin
clot, osteoprogenator cell migration.
Increase rate and extent of bone accumulation.
Increased surface area renders greater
osteoblastic proliferation, differentiation
of surface adherent cells.
Increased cell attachment growth and
differentiation.

Increased rough surfaces :

Increased risk of peri implantitis
Increased risk of ionic leakage /
corrosion
 BONE FACTOR
Initial implant stability
• Bone quality  bone with
well formed cortex and
densely trabaculated
medullary spaces

 Bone quantity  Refers to

the dimension of available
bone in reference to length,
width and depth.
 LEKHOLM AND ZARB CLASSIFICATION 1985

Class I : Jaw Class II : Class III : Class IV :

consist almost Thick compact Thin cortical Thin cortical
exclusively of bone surrounds bone surrounds bone surrounds
homogeneous highly highly loose, spongy
compact bone trabecular core trabecular core core
 MISCH CLASSIFICATION 1988

D1 D2 D3 D4
 According to Branemark and Misch

D1 and D2 bone  initial stability / better osseointegration

D3 and D4  poor prognosis

D1 bone – least risk

D4 bone - most at risk

Selection of implant

D1 and D2 – conventional threaded implants

D3 and D4 – HA coated or Titanium plasma coated implants

Implantation bed / host bed
Objective  Healthy implant host site
Nature of the host site - vascularity
- cellularity (osteogenic potential)
Two Factors
•Patient Considerations - Age

•History of proposed host bed -Previous irradiation

- Infection
- History of smoking
- Advanced ridge resorption
- Osteoporosis or osteoporotic like
bone lesion
Success criteria of implants
Schuitman and Schulman criteria (1979)
1) The mobility of the implant must be less than 1mm when
tested clinically.
2) There must be no evidence of radiolucency
3) Bone loss should be less than 1/3rd of the height of the
implant
4) There should be an absence of infection, damage to structure
or violation of body cavity, inflammation present must be
amneable to treatment.
5) The success rate must be 75% or more after 5 years of
functional service.
Albrektson and Zarb G (1980)
1) The individual unattached implant should be immobile when
tested clinically
2) The radiographic evaluation should not show any peri - implant
radiolucency
3) Vertical bone loss around the fixtures should be less than
0.2mm annually after first year of implant loading.
4) The implant should not show any sign and symptom of pain,
infection, neuropathies, parastehsia, violation of mandibular
canal and sinus drainage.
5) Success rate of 85% at the end of 5 year observation period and
80% at the end of 10 year service.
6) Implant design allow the restoration satisfactory to patient and
dentist. - Smith and Zarb (1989)
•Radiographs