Dental implantology 5th year Prosthodontics Lect. Dr.

Mustafa Saadi Ali

Dental implantology
Definitions
Dental implant: a prosthetic device made of alloplastic material(s) implanted into
the oral tissues beneath the mucosal and/or 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 and/or on the jaw bone to support a fixed or
removable dental prosthesis.

Implant prosthodontics: it is the branch of implant dentistry concerning with the

restorative phase following implant placement and the overall treatment plan
components before the placement of dental implants.
It is the phase of implantology concerning with the replacement of missing teeth
and/or associated structures by restorations that are attached to dental implants.

Implant prosthesis: dental prosthesis, such as artificial crown, fixed complete

denture, fixed partial denture, removable complete overdenture, removable
partial overdenture, as well as maxillofacial prothesis, which are supported and
retained in part or whole by dental implants.

Implant system: dental implant components that are designed to mate together. It
consists of the necessary parts and instruments to complete the implant body
placement and abutment components attachment. An implant system can
represent a specific concept, inventor, or patent.

Classification of dental implants

Dental implant can be classified based on placement within tissue into:
1) Endosteal (endosseous) implants: These implants are inserted into the
dentoalveolar and/or basal bone and protrude through the mucoperiosteum. These
are the most common type and can be used in all areas of the mouth. They come
in different shapes, like root-form cylindrical cones or screws, thin plates or
blades, pins, or discs.
2) Subperiosteal implants: These implants are placed directly over the surface
of the bone cortex and just beneath the periosteum. They are in the form of open
meshes or custom-made frameworks to fit over the bone.

1
Dental implantology 5th year Prosthodontics Lect. Dr. Mustafa Saadi Ali

3) Transosteal (transosseous) implants: These implants pass through the full

thickness of the jaw bone, penetrating both cortical plates. They are only used in
the anterior region of the mandible in cases of severe ridge resorption.

Classification of endosseous implants

1) According to the surgical stages:
• Single-stage design (none submerged) (transgingival): the body of the
implant is inserted into the bone with its abutment portion penetrating
through the mucoperiosteum during the healing period.
• Two-stage design: in this design the implant body is completely embedded
in bone for complete osseointegration. The implant body is then exposed
and the healing abutment is placed for soft tissue healing before the
impression is made for prosthesis fabrication.
2) According to the time of placement:
• Immediate implants: they are placed into a prepared extraction socket
immediately following tooth extraction.
• Early implants: they are placed within 4-8 weeks after the tooth loss.
• Delayed implants: they are placed within 3-6 months after tooth extraction,
when complete healing and bone remodeling occur.
3) According to the time of prosthetic loading:
• Immediately loaded implants: an acrylic resin prosthesis which is designed
to be out of occlusion is placed immediately after implant placement,
especially in anterior region for esthetic purposes.
• Delayed loading implant: delayed loading is done in maxillary implants
after 4-6 months and in mandibular implants after 3-4 months to allow for
better osseointegration due to the difference in bone composition.

Osseointegration and factors affecting osseointegration

Osseointegration: the apparent direct attachment or connection of osseous tissue
to an inert, alloplastic material without intervening fibrous connective tissue. Or
it is the direct bone anchorage to an implant body, which can provide a foundation
to support prosthesis.
Dr. Per-Ingvar Branemark, a Sweden professor, developed the concept of
osseointegration when surgically inserted a titanium implant into the tibia of a
rabbit.

2
Dental implantology 5th year Prosthodontics Lect. Dr. Mustafa Saadi Ali

The factors affecting the healing of bone around dental implants:

1) Surgical technique: All surgical procedures are traumatic. The level of
trauma is a critical factor that determines whether healing will progress toward
fibrous or osseous integration. Surgical preparation on hard tissue causes a
necrotic zone of bone (interface) due to cutting of blood vessels, frictional
heat, and vibrational trauma. Excessive trauma leads to fibrous encapsulation
of the implant. Surgical trauma must be minimized during all aspects of
implant surgery to optimize success rates. The temperature for impaired bone
regeneration has shown to be 44 C⁰ to 47 C⁰ for one minute.
2) Premature loading: Time should be allowed for healing of necrotic bone
formed due to surgery. Movement of the implant during this healing phase will
result in fibrous encapsulation. For this reason, it is recommended by many
operators to keep the recently placed implants unloaded for a period of two to
eight months depending on the clinical situation, implant coating, location of
the implant, and whether the implant is placed into bone grafts.
3) Surgical fit: Even with the best technical precautions, bone contacts only
portions of the implant and a perfect microscopic contact is not possible. A
longer healing period will be required before loading implants when surgical
fit less than optimal.
4) Bone quality and quantity: The mandible has a denser cortex and a coarser
thicker cancelli than the maxilla. When we go posterior, jaws tend to have a
thinner, more porous cortex, and finer lacunae. Bone regeneration is more
likely to progress at a faster rate if the surrounding is denser. It is very frequent
to find that bone amount is not enough for implant placement. The following
measures can be done to overcome this problem:
• The use of short implants.
• Changing the implant angulations.
• Ridge augmentation.
• Trans positioning of the neurovascular bundle in the mandible.
• Subantral augmentation (sinus lift) in the maxilla.
5) Physical condition of the patient: Nutritional status, aging, diabetes mellitus,
blood diseases, corticosteroids therapy and radiation treatment are among
many factors which can affect healing.

Team approach of implant treatment

Some authors believe that the same operator should place and restore the
implants. The rationale is that it is more efficient form a patient's point of view.
It also allows the practitioner more freedom in changing the predetermined
3
Dental implantology 5th year Prosthodontics Lect. Dr. Mustafa Saadi Ali

position of the implants at the time of surgery. Because the same individual is
responsible for the prosthetic treatment, these changes can be incorporated into
the treatment plan more readily.
Others believe that a team approach is more appropriate to follow. A surgeon
should place the implants, and a prosthetic dentist should complete the
restoration. Because it allows for the utilization of expertise of the two
individuals, there is a built- in second opinion in the approach. Additionally, there
is shared responsibility and shared liability.
Regardless of the philosophy followed, it is well to delineate the responsibilities
at each stage of implant therapy, and it should be clear that dental implant is a
prosthetic technique with a surgical step.

The responsibility of the prosthodontist:

1) Perform the initial clinical evaluation.
2) Perform the initial radiographic evaluation.
3) Obtain the diagnostic casts.
4) Obtain the diagnostic wax- up.
5) Determine the location and number of implants and fabricate a surgical
template.
6) Select the proper abutment following the implant exposure.
7) Design and fabricate the prosthesis.
8) Provide oral hygiene care and instructions.
9) Ensure recall of the patient to evaluate maintenance and provide care as
required.

The responsibility of the oral surgeon:

1) Confirmation of the radiographic evaluation.
2) Confirmation of the physical evaluation.
3) Determination of the location and number of implants within limits set by the
prosthodontist.
4) Placement of the implants (first stage surgery).
5) Uncovering of the implants (second stage surgery).
6) Confirmation of osseointegration of the implants.

4
Dental implantology 5th year Prosthodontics Lect. Dr. Mustafa Saadi Ali

Indications of implant prosthesis

1) Edentulous patient with history of difficulty in wearing removable dentures.
2) When there is severe change in complete denture bearing tissues.
3) Poor oral muscular coordination.
4) Para-functional habits that compromise prosthesis stability.
5) Unrealistic patient expectations for complete dentures.
6) Hyperactive gag reflex.
7) Low tissue tolerance of supporting mucosa.

Contraindications of implant prosthesis

1) High dose irradiated patients.
2) Patient with psychiatric problems such as psychosis.
3) Hematological disorders.
4) Pathology of hard and soft tissues.
5) Patient with drug, alcohol or tobacco chewing abuse.

Implant components
1. Implant fixture (implant body)
The portion of a dental implant that provides support for the abutment(s)
through adaptation upon (eposteal), within (endosteal) or through (transosteal)
the bone. The body is that portion of the implant designed to be surgically
placed into the bone. It may extend slightly above the crest of the ridge.
2. Healing (cover) screw
The component of an endosteal dental implant system used to seal, usually on
an interim basis, the dental implant body during the healing phase after
surgical placement. The purpose of the healing screw is to maintain patency
of the internal threaded section for subsequent attachment of the abutment
during the second stage surgery.
3. Healing abutment (gingival former) (Interim abutment)
Any dental implant abutment used for a limited time to assist in healing or
modification of the adjacent tissues. After a prescribed healing period that
allows a supporting interface to develop, second stage surgery is performed to
uncover or expose the implant and attach the transepithelial portion or
abutment. This transepithelial portion is termed a second stage permucosal
extension, because it extends the implant above the soft tissue and results in
the development of a permucosal seal around the implant.

5
Dental implantology 5th year Prosthodontics Lect. Dr. Mustafa Saadi Ali

4. Implant abutment
The portion of a dental implant that serves to support and/or retain any
prosthesis. Three main categories of implant abutments are described
according to the method by which the prosthesis or superstructure is retained
to the abutment:
• Abutment for screw retained prosthesis: uses a screw to retain the
prosthesis or superstructure.
• Abutment for cement retained prosthesis: uses dental cement to retain the
prosthesis or superstructure.
• Abutment for attachment: uses an attachment device to retain the
removable prosthesis.
Each of the three types of abutments is further classified into straight and
angled abutments, describing the axial relationship between the implant body
and abutment.
5. Abutment screw
The abutment is secured to the implant body by the abutment screw.
6. Hygiene screw
It is placed over the abutment between prosthetic appointments to prevent
debris and plaque from entering the screw space of the abutment.
7. Transfer coping (impression coping)
Any device that registers the position of the dental implant body or dental
implant abutment relative to adjacent structures.
8. Implant analog (laboratory analog)
An analog is something that is analogous or similar to something else. Implant
analog is used in the fabrication of the master cast to replicate the retentive
portion of the implant body or abutment. After impression, the corresponding
analog is attached to the transfer coping and the assembly is poured in stone
to fabricate the master cast.
9. Coping (gold cylinder)
It is a thin covering usually designed to fit the implant abutment and serve as
the connection between the abutment and the prosthesis or superstructure. A
prefabricated coping usually is a plastic pattern cast into the metal
superstructure or prosthesis.
10.Coping screw
The coping is secured to the abutment with a coping screw.

6
Dental implantology 5th year Prosthodontics Lect. Dr. Mustafa Saadi Ali

Prosthetic options in implant dentistry

FP-1 fixed prosthesis: replaces only the crown; looks like a natural tooth. An
FP-1 is a fixed restoration and appears to the patient to replace only the
anatomical crowns of the missing natural teeth. To fabricate this restoration type,
there must be minimal loss of hard and soft tissues. The volume and position of
the residual bone must permit ideal placement of the implant in a location similar
to the root of a natural tooth. The final restoration appears very similar in size and
contour to most traditional fixed prostheses used to restore or replace natural
crowns of teeth.

7
Dental implantology 5th year Prosthodontics Lect. Dr. Mustafa Saadi Ali

FP-2 fixed prosthesis: replaces the crown and a portion of the root; crown
contour appears normal in the occlusal half but is elongated or hyper-contoured
in the gingival half. An FP-2 fixed prosthesis appears to restore the anatomical
crown and a portion of the root of the natural tooth. The volume and topography
of the available bone are more apical compared with the ideal bone position of a
natural root (1–2 mm below the cement–enamel junction) and dictate a more
apical implant placement compared with the FP-1 prosthesis. As a result, the
incisal edge of the restoration is in the correct position, but the gingival third of
the crown is overextended, usually apical and lingual to the position of the
original tooth. These restorations are similar to teeth exhibiting periodontal bone
loss and gingival recession.

FP-3 Fixed prosthesis: replaces missing crowns and a portion of the edentulous
site; prosthesis most often uses denture teeth and acrylic gingiva but may be
porcelain to metal. The FP-3 fixed restoration appears to replace the natural teeth
crowns and has pink colored restorative materials to replace a portion of the soft
tissue, especially the interdental papillae. As with the FP-2 prosthesis, the original
available bone height has decreased by natural resorption or osteoplasty at the
time of implant placement. To place the incisal edge of the teeth in proper position
for esthetics, function, lip support, and speech, the excessive vertical dimension
to be restored requires teeth that are unnatural in length. However, unlike the
patient requirements for an FP-2 prosthesis, the patient may have a normal to high
maxillary lip line during smiling or a low mandibular lip line during speech. As a
consequence, the soft tissue drape should also be replaced. Prosthetic replacement
of the soft tissue drape (FP-3 prosthesis) is most often desirable when multiple
adjacent teeth are missing.

8
Dental implantology 5th year Prosthodontics Lect. Dr. Mustafa Saadi Ali

RP-4 removable prosthesis: is a removable prosthesis (overdenture) supported

completely by implants (usually with a superstructure bar). The restoration is
rigid when inserted: overdenture attachments usually connect the removable
prosthesis to a low-profile tissue bar or superstructure that splints the implant
abutments. Usually, five to seven implants in the mandible and six to eight
implants in the maxilla are required to fabricate completely implant supported
RP-4 prostheses in patients with favorable dental criteria.

RP-5 removable prosthesis: overdenture supported by both soft tissue and

implants (may or may not have a superstructure bar). RP-5 is a removable
prosthesis combining implant and soft tissue support. The amount of implant
support is variable. A completely edentulous mandibular overdenture may have
(1) two or three anterior implants independent of each other primarily for
retention; (2) splinted implants in the canine regions to enhance retention and
stability, (3) three splinted implants in the premolar and central incisor areas to
provide improved retention and lateral stability; or (4) four or five implants
splinted with a cantilevered bar to improve retention, stability, and support which
reduces soft tissue abrasions and limits the amount of soft tissue coverage needed
for prosthesis support. The primary advantage of an RP-5 restoration is the
reduced cost because fewer implants may be inserted compared with a fixed
restoration and there is less demand for bone augmentation, often required for
additional implants. The prosthesis is very similar to traditional overdentures
supported by natural teeth.

Screw-retained versus cemented fixed implant prostheses

Both types of prosthesis retention can give excellent long-term results, although
the retrievability afforded by screw-retained prostheses clearly offers the safer
and most versatile option.
Nonetheless some dentists prefer the cementation protocol since this approach
precludes visibility of access openings in the occlusal or facial surfaces of the
artificial teeth. It should however be emphasized that any sub-mucosal extension
of a prosthesis could predispose to an iatrogenic peri-implant inflammation with
marginal bone loss if all cement remnants are not removed.
For full-arch prostheses, a screw-retained design is recommended as any
maintenance procedure or subsequent treatment can be performed more
efficiently by removing the prosthesis; for example, in the case of technical
problems such as fracture of the veneering material or fracture of abutment screw
or in treatment of mucositis and peri-implantitis.
9
Dental implantology 5th year Prosthodontics Lect. Dr. Mustafa Saadi Ali

Impression techniques
1) Implant level impressions
• Transfer (closed tray).
• Pick-up (open tray).
2) Abutment level impressions
• Direct technique.
• Indirect technique.

1) Implant level impressions

Traditionally, there are 2 different implant impression techniques for transferring
the impression copings from the implant to the impression.
• Transfer (closed tray) technique
The transfer technique uses tapered copings and a closed tray to make an
impression. The copings are connected to the implants, and an impression is made
and removed from the mouth, leaving the copings intraorally. Subsequently the
copings are removed and connected to the implant analogs, and then the coping-
analog assemblies are inserted in the impression before pouring the definitive
cast.

10
Dental implantology 5th year Prosthodontics Lect. Dr. Mustafa Saadi Ali

The clinical situations which indicate the use of the closed tray technique are:
when the patient has limited interarch space, tendency to gag, or if it is too
difficult to access an implant in the posterior region of the mouth.

• Pick-Up (Open tray) technique

Conversely, the pick-up impression uses square copings and an open tray (a tray
with an opening), allowing the coronal ends of the impression coping screw to be
exposed. Before separating the implants, the copings screws are unscrewed to be
removed along with the impression. The implant analogs in the impression are
connected to the copings to fabricate the definitive cast. Pick-up technique takes
advantage of impression materials having rigid properties and eliminate the error
of permanent deformation of impression materials because the transfer coping
remains within the impression until the master model is poured and separated.

Advantages:
- Reduce the effect of implant angulation.
- Reduce the deformation of the impression material.

Disadvantages:
There may be some rotational movement of the impression transfer when
securing the implant analog.

11
Dental implantology 5th year Prosthodontics Lect. Dr. Mustafa Saadi Ali

2) Abutment level impression

• Direct techniques
The implant abutment may be restored as a natural tooth restoration. The
abutment (usually prefabricated) is inserted into the implant body. After
preparation of the abutment in the mouth, an impression is made of the abutment.
A stone cast is poured, and an individual die of the abutment is trimmed. The
restoration is fabricated very similar to a tooth.
Advantages:
- Familiar to the restoring dentist.
- No laboratory analog components are required.
- Splinting crowns together is less complicated, because of manufacturer
precision since transfer components and analogs are not required.
- Reduced cost because analogs and laboratory fees for abutment preparation
are eliminated.
Disadvantages:
- The abutments are prepared in the mouth.
- Retraction cord placement is required in esthetic zones or when additional
abutment height is required for prosthesis retention.

• Indirect technique
The indirect technique uses a closed tray to make an impression. An indirect
technique uses an elastic impression material. The abutment is screwed into the
implant body and remains in place when a traditional “closed-tray” impression is
set and removed from the mouth. The abutment is removed from the implant body
in the mouth, connected to an implant body analog, and then reinserted into the
closed-tray impression before pouring the definitive cast; hence, the transfer is
“indirect.”
12
Dental implantology 5th year Prosthodontics Lect. Dr. Mustafa Saadi Ali

Occlusion in implant-supported prostheses

There are few differences between natural teeth and implants, which need to be
considered when restoring implants.
1) Natural teeth are associated with high occlusal awareness (proprioception) of
about 20 μm. Besides the proprioception, the presence of periodontal ligament
as a shock absorber in a natural tooth brings about an apical intrusion. While
in implant-supported prosthesis, the lack of proprioception and the absence of
periodontal shock absorption are often associated with increased impact force
than with a tooth-supported prosthesis.
2) In case of occlusal trauma, mobility can develop in a tooth as well as in an
implant. However, upon removal of the trauma, mobility can be reduced or
controlled with a natural tooth, while no such response can be noted in an
implant.
3) In general, the diameter of natural teeth is larger than the diameter of implants.
Also, the cross-section of implants is rounded and the diameter is selected
primarily according to bone available, not according to the load that it is
anticipated to be subjected to.
The presence of such differences between natural teeth and implants led to the
establishment of implant-protective occlusion (IPO).

Implant-protective occlusion (IPO)

This occlusal concept refers to an occlusal scheme that is often unique and
specifically designed for the restoration of endosteal implant. A primary goal of
IPO is to maintain the occlusal load (that has to be transferred to the implant body)
within the physiologic limits of each patient.

Significance of IPO on osseointegrated endosteal implants

1. There are no specific defense mechanisms against occlusal forces in implant,
so poorly restored occlusion has deleterious effect on implants.
2. Prosthesis must be fabricated as accurately as possible in order to achieve long
standing success and occlusion should be key factor in overall success rate.
3. An impact force can have destructive effects on prosthesis, implants, and
supporting bone. The IPO has a protective role by reducing the effect of impact
forces and transferring the loads to the supporting bone through the implant
body.

13
Dental implantology 5th year Prosthodontics Lect. Dr. Mustafa Saadi Ali

Goals of implant-protective occlusion

• Bilateral simultaneous contact.
• No premature contacts in retruded contact position (RCP).
• Smooth and even lateral excursive movement with no nonworking
interferences.
• Equal distribution of occlusal forces.
• Freedom from deflective contacts in intercuspal position (IP). There is some
evidence that a degree of freedom in horizontal movement is helpful. Shallow
cusp angles may be associated with reduced horizontal loading of an implant.
• Anterior guidance whenever possible.

Considerations for implant-protective occlusion

1) No premature occlusal contacts or interferences:
Excessive occlusal load during premature contact causes severe crestal bone
resorption and loss of osseointegration. Movement patterns of the natural tooth
and the implant are different. The implant has no periodontal ligaments, concerns
center around the potential for the “nonmobile” implant to bear the total load of
the prosthesis compared to the “mobile” natural tooth.
The difference in vertical movement of teeth and implants in the same arch is 28
μm. The initial occlusal contacts should account for this difference or implants
will sustain greater loads. Occlusal adjustment should be done to eliminate
premature contacts on implant restoration. Thin articulating paper (less than 25μ
thickness) is then used for the initial implant occlusal adjustment in centric
relation occlusion under a light tapping force. The implant prosthesis should
barely contact, and the adjacent teeth should exhibit greater initial contacts. Only
axial occlusal contacts should be present on the implant crown. Once the
equilibration with a light bite force is completed, a heavier centric occlusal force
is applied. The contacts should remain axial over the implant body and may be of
similar intensity on the implant crown and the adjacent teeth under greater bite
force to allow all elements to react similar to the occlusal load. Hence to
harmonize the occlusal forces between implants and teeth, a heavy bite force
occlusal adjustment is used because it depresses the natural teeth, positioning
them closer to the depressed implant position and equally sharing the load.

14
Dental implantology 5th year Prosthodontics Lect. Dr. Mustafa Saadi Ali

Light tapping force Heavier centric occlusal force

The initial lateral movement of healthy anterior teeth ranges from 68 to 108 μm
before secondary tooth movement. Implant lateral movements are not immediate
and range from 10 to 50 μm. Because of the greater discrepancies in lateral
movement, the occlusal adjustment in this direction is more critical to implant
success and survival. A light force and thin articulating paper are used, and the
implant crown exhibits minimum contact compared with the natural abutment
crown. A heavy bite force is then used to establish equal occlusal contacts for all
implant crowns and natural teeth.

2) Influence of surface area:

An important part of IPO is the adequate surface area to sustain load transmission
to the prosthesis. Wider diameter root-form implants have a greater area of
contact at the crest than narrow implants which reduces the mechanical stress at
the crest. When narrow diameter implants are used in regions that receive greater
loads, additional splinted implants are indicated to compensate for the design.

3) Crown cusp angle:

Occlusal contact along an angled cusp results in an angled load to the crestal bone.
Posterior implant crown should have shallow cusps and wider central fossa
perpendicular to implant body. Opposing cusp should be modified to occlude in
the fossa of the implant crown.

4) Occlusal contact positions:

The occlusal contact position determines the direction of force to the implant
body. The ideal implant body (fixture) position is usually under the central fossa
and maybe 1-2 mm to the facial aspect (when bone is abundant) to be under the

15
Dental implantology 5th year Prosthodontics Lect. Dr. Mustafa Saadi Ali

buccal cusp of the mandible and to improve the esthetic emergence of maxillary
implant crowns.
The ideal primary contacts should reside within the diameter of an implant.
Secondary occlusal contacts should remain within 1 mm of the periphery of
implant. The marginal ridge contact is considered a cantilever load because the
implant is not under the marginal ridge. Marginal ridge contacts should be
avoided.

5) Implant crown contour:

A wide occlusal table favors offset contacts during function or parafunction.
Narrower implant bodies are even more vulnerable to occlusal table width and
offset loads. Wider root form implants can accept a broader range of vertical
occlusal contacts while still transmitting lesser forces at the permucosal site under
offset loads. Therefore, in IPO the width of the occlusal table is directly related
to the width of the implant body.
Restorations mimicking the occlusal anatomy of natural teeth often result in offset
loads (increased stress), complicated home care and increased risk of porcelain
fracture. In non-esthetic regions of the mouth, the occlusal table should be
reduced in width compared with natural teeth.

16