Dental Implantology

th
5 year Dr. Auday M. Al-Anee

Implant Treatment: Advanced Concepts

Immediate Postextraction Placement of Implants
When implant placement is planned before tooth extraction, consideration should
be given to the most desirable time for implant placement. The implant may be
placed immediately (i.e., at the time of extraction), early (i.e., 2 months after
extraction), or late (i.e., more than 6 months after extraction). Each of these times
has its indications, advantages, and disadvantages.
The primary advantage of immediate placement is that this allows the overall
shortest healing time and combines tooth extraction with surgical implant
placement. Placing a provisional restoration at the same procedure may provide the
best opportunity for maintenance of soft tissue anatomy and the best immediate
and long-term esthetic results. The primary disadvantage of immediate placement
is related to the difference in the anatomy of the root or roots of the extracted tooth
compared with the shape and size of the implant. This is particularly true of a
multirooted tooth that is being replaced by an implant. Even in the case of an
incisor, the difference in the shape of the root and that of the implant creates some
difficulty in implant placement. Another disadvantage is that if the implant is
exposed to excessive occlusal forces, the immediate and long-term stability of the
implant can be jeopardized.
Immediate placement can be considered if the tooth to be removed is not infected
and can be removed without the loss of alveolar bone. A critical component in the
success of this technique is to complete the extraction of the tooth with minimal
bone removal and without distorting or weakening the bony support. An atraumatic
extraction technique using periotomes will help minimize damage to bone and help
facilitate implant placement. Initial implant stability at the time of placement is
also critical to long-term success. When the implant is placed, at least 4 mm of the
implant apex should be precisely seated in firm bone to provide this initial
stability. Surgical guides are extremely helpful in placing the implant because
drilling the implant site at the correct angulation can sometimes be difficult
because the drill can be easily deflected when bouncing off the wall of the socket.
The implant should be countersunk slightly below the height of crestal bone to
allow for resorption of bone resulting from extraction. In the esthetic zone
(maxillary anterior), the platform of the implant is ideally placed 3 mm below the

1
 Dental Implantology
th
5 year Dr. Auday M. Al-Anee
free gingival margin. This allows for development of optimal emergence contour
of the final restoration and soft tissue maintenance. In general the implant is also
positioned 1 mm palatal to the center of the extracted tooth root. This accounts for
anticipated facial bone and soft tissue remodeling that decreases the facial crestal
volume.
The gap between the implant and the residual tooth socket must be evaluated and
managed according to its size. If the gap is less than 1 mm and the implant is
stable, often no treatment modification is needed. If the gap is greater than 1 mm,
grafting with a particulate bone material may be indicated. At present the need for
this is controversial. In most cases, with flapless, atraumatic extraction techniques,
primary closure may not be possible or desirable. In this situation, a resorbable
collagen pellet may be placed over the implant and held in place with a figure-of-
eight suture. The surgeon may consider extending the time allowed for integration
before loading.
In isolated cases, restoration at the time of implant placement may be considered. It
is extremely important to ensure that the restoration is in ideal firm contact with
adjacent teeth, which will help to reduce unfavorable loading on the implant until it
is osseointegrated.
Bone Grafting and Graft Substitutes
In many cases, areas to be restored with implants have insufficient bone for
implant placement. This may be a result of extraction and bone atrophy, sinus
pneumatization, previous trauma, congenital defects, or removal of pathologic
lesions. In these cases, bone will need to be augmented to provide adequate support
for implant placement. Several potential sources of graft material can be
considered, depending on the volume and configuration of bone needed.
Autogenous Grafts
Autogenous bone can be harvested from several anatomic areas. Intraorally, bone
can be harvested from the mandibular symphysis, ramus, or maxillary tuberosity
areas. Bone in the tuberosity is primarily cancellous, whereas in the ramus–
posterior body area of the mandible, the bone is primarily cortical. The symphysis
provides the best intraoral source for a reasonable volume of cortical and
cancellous bone. When more bone is required for situations such as atrophic
edentulous mandible or bilateral sinus lifts, an extraoral site should be considered
if autogenous bone is to be used. The most common site of graft harvest is the

2
 Dental Implantology
th
5 year Dr. Auday M. Al-Anee
anterior iliac crest. Other areas where bone is sometimes harvested include the
tibia, the fibula, and the calvarium.
Allografts
Allogeneic bone grafts procured from cadavers are processed to achieve sterility
and decrease the potential for immune response. The sterilization process destroys
the osteoinductive nature of the graft; however, the graft provides a scaffold,
allowing bone ingrowth (osteoconduction). Bony incorporation, followed by
remodeling and resorption, occurs during the healing phase. Granular forms of
allogeneic graft material provide increased surface area and improved adaptation
within the graft and are the most commonly used for augmenting alveolar ridge
contour defects. The advantages of allogeneic bone grafting include the avoidance
of an additional donor site, unlimited availability, and the fact that patients can
undergo this type of procedure in an outpatient setting. The disadvantage is that a
significant amount of grafted bone is resorbed, which results in a much smaller
volume of bone for implant placement.
Xenografts
Xenografts are derived from the inorganic portion of bone harvested from a species
that is genetically different from the graft recipient. The most common source of
xenografts is bovine bone. The advantages and disadvantages are similar to those
of allografts, including significant postgrafting resorption.
Bone Morphogenetic Proteins
One of the most exciting recent advancements in bone grafting has been the
extensive research related to bone morphogenetic proteins (BMPs). BMPs are a
family of protein factors that have been isolated and applied to reconstruction of
the maxillofacial skeleton. These proteins have the ability to enhance bone graft
healing and, in many cases, substitute for other graft materials. BMP are growth
factors, belonging to the transforming growth factor-β family, induces new bone
formation by inducing differentiation of multi-potent cells.
Recombinant human BMP 2 (rhBMP-2) has been isolated and has now been
produced and packaged for use in grafting procedures. The BMP is placed on
carriers, usually absorbable collagen sponges, to facilitate placement in the graft
site. BMP can be positioned around implants within the extraction sites, aiding in
osseointegration.

3
 Dental Implantology
th
5 year Dr. Auday M. Al-Anee
In larger defects, the BMP is usually combined with osteoconductive allogeneic
materials to expand the graft volume and to help place, shape, and contain the graft
material. BMP with a collagen sponge carrier can be used for sinus lifting and
reconstruction of non–load-bearing bony defects. The obvious advantages include
eliminating the need for donor site surgery and improved bone formation at the site
of augmentation. The primary disadvantages include significant postoperative
edema and the cost of the BMP.
Two problems associated with any type of grafting include containment and
shaping of the graft material and prevention of fibrous tissue ingrowth during the
healing phase. Placement of particulate grafts to augment alveolar ridges often
requires some type of containment device or material to facilitate the ideal ridge
size and shape. Materials used to contain and shape the graft can also be effective
in eliminating the unfavorable invasion of soft tissue during healing.
Guided bone regeneration is a process that allows bone growth while retarding the
ingrowth of fibrous connective tissue and epithelium. Many bone defects will
regenerate with new bone if the invasion of connective tissue from adjacent soft
tissue can be prevented. Guided bone regeneration involves using a barrier that is
placed over the bony defect to prevent fibrous tissue ingrowth while the bone
underlying the barrier has time to grow and fill the defect. This technique is
particularly useful in the treatment of buccal dehiscence, where labiobuccal
(horizontal) augmentation of bone is required. Guided bone regeneration can be
performed simultaneously with implant placement or before stage I. A variety of
materials may serve as barriers to fibrous tissue ingrowth. Expanded
polytetrafluoroethylene (Gore-Tex) is the most extensively tested material.
Resorbable materials are also now available, eliminating the necessity of removal.
Thin, malleable titanium mesh is also a commonly used material facilitating
maintenance of graft shape while eliminating extensive fibrous ingrowth. Titanium
mesh trays can be created by trimming and contouring flat titanium mesh at the
time of surgery, or they can be fabricated prior to surgery using diagnostic
mounted dental casts or computer-aided design and computer-aided manufacturing
technology.
Mandibular Augmentation
Augmentation grafting adds strength to an extremely deficient mandible and
improves the height and contour of available bone for implant placement in
denture-bearing areas. Superior border augmentation with a bone graft is often

4
 Dental Implantology
th
5 year Dr. Auday M. Al-Anee
indicated when severe resorption of the mandible results in inadequate height and
contour and potential risk of fracture or when the treatment plan calls for
placement of implants in areas of insufficient bone height or width.
Neurosensory disturbances from inferior alveolar nerve dehiscence at the superior
aspect of the mandible also can be improved with superior border grafting. Sources
of graft material include autogenous bone, allogeneic bone, or both, often
combined with BMP (off-label use). Historically, autogenous bone has been the
most biologically acceptable material used in mandibular augmentation.
Disadvantages of the use of autogenous bone include the need for donor site
surgery and the possibility of the significant resorption that occurs after grafting.
The use of allogeneic bone eliminates the need for a second surgical site and has
been shown to be useful in augmenting small areas of deficiency in the mandible.
Use of allogeneic bone seems to be most effective in augmenting the width of the
alveolar ridge and is much less effective in improving the height (vertical
augmentation) of a deficient mandible. Current techniques for superior border
augmentation of the mandible frequently involve some combination of block
grafting, supplemented with an allogeneic material such as freeze-dried bone
mixed with BMP often contained in some type of mesh tray.
Maxillary Augmentation
Severe resorption of the maxillary alveolar ridge presents a significant challenge to
the prosthetic reconstruction of the dentition. When moderate to severe maxillary
resorption does occur, the larger denture-bearing area of the maxilla may allow
prosthetic rehabilitation without bony augmentation. In certain cases a severe
increase in interarch space, loss of palatal vault, interference from the zygomatic
buttress area, and absence of posterior tuberosity notching may make it difficult to
construct proper dentures; augmentation should then be considered.
Onlay Bone Grafting
Bone grafting of the edentulous atrophic maxilla with an autogenous rib was first
described by Terry in 1984. Maxillary onlay bone grafting is indicated primarily in
the presence of severe resorption of the maxillary alveolus that results in the
absence of a clinical alveolar ridge and loss of adequate palatal vault form.
Maxillary onlay grafting is usually accomplished by using some combination of
autogenous bone (corticocancellous blocks or particulate marrow), allogeneic
bone, and BMP (off-label use), often contained in some type of mesh tray. When
blocks of corticocancellous bone are used, they can be secured to the maxilla with
5
 Dental Implantology
th
5 year Dr. Auday M. Al-Anee
small screws, eliminating mobility and decreasing resorption. Cancellous bone is
then packed around the grafts to improve contour. Implants can be placed at the
time of grafting in some cases, but placement is often delayed to allow initial
healing of the grafted bone.
Sinus Lift
Rehabilitation of the maxilla using implants is frequently problematic because of
the extension of the maxillary sinus into the alveolar ridge area. In many cases the
actual size and configuration of the maxilla are satisfactory in terms of the height
and width of the alveolar ridge area. However, extension of the maxillary sinuses
into the alveolar ridge may prevent placement of implants in the posterior
maxillary area because of insufficient bony support. The sinus lift is a bony
augmentation procedure that places graft material inside the sinus cavity but
external to the membrane and augments the bony support in the alveolar ridge area.
When only a few millimeters of augmentation are needed in conjunction with
simultaneous implant placement, an indirect sinus lift is effective. This procedure
relies on the lack of density found in maxillary cancellous bone. The initial drill is
used to locate the angulation and position of the planned implant. The depth is
drilled just short of the sinus floor. Osteotomes are then used to enlarge the site
progressively. The osteotome is cupped on the end and compresses the walls of the
osteotomy site; it also scrapes bone from the sides of the wall, pushing it ahead.
The bone of the sinus floor is pushed upward, elevating the sinus membrane and
depositing the bone from the lateral wall and apex of the osteotomy into the sinus
below the membrane. If needed, additional graft material can be introduced
through the implant site.
When more bony augmentation is needed, an open approach to the sinus is
necessary. In this technique, an opening is made in the lateral aspect of the
maxillary wall, and the sinus lining is carefully elevated from the bony floor of the
sinus. After elevation of the sinus membrane, the graft material is placed in the
inferior portion of the sinus, below and external to the sinus membrane.
Allogeneic, autogenous, xenogeneic bone, BMP, or a combination of these
materials can be used as a graft source. Perforation of the sinus membrane can
occur during exposure of the maxillary sinus floor. Perforations are usually
covered with redundancy of the elevated membrane and a “patch” of resorbable
membrane material. These measures allow placement of the graft material with
protection from a direct sinus communication. If insufficient bone is available to

6
 Dental Implantology
th
5 year Dr. Auday M. Al-Anee
provide initial implant stability, the graft is allowed to heal for 3 to 6 months, after
which the first stage of implant placement can begin in the usual fashion.
If enough bone is available to obtain initial implant stability (usually 4 to 5 mm),
then implant placement can be accomplished simultaneously with sinus grafting.
This procedure can be performed as outpatient surgery. A properly relieved
removable prosthesis can usually be worn after surgery, during the healing period.
Alveolar Ridge Distraction
Trauma, congenital defects, and resection of bony pathologic conditions often
create a bone defect inadequate for immediate reconstruction with implants.
Considerable soft tissue defects, including loss of attached gingiva, keratinized
tissue, or mucosa, frequently accompany the bony discrepancy. Distraction
osteogenesis has been used to correct these alveolar deficiencies. Distraction
osteogenesis involves cutting an osteotomy in the alveolar ridge. An appliance is
then screwed directly into the bone segments. After an initial latency period of 5 to
7 days, the appliance is gradually activated to separate the bony segments at
approximately 1 mm per day. The gradual tension placed on the distracting bony
interface produces continuous bone formation. In addition, adjacent tissue,
including mucosa and attached gingiva, expands and adapts to this gradual tension.
Because the adaptation and tissue genesis involve a variety of tissue types in
addition to bone, this concept should also include distraction histiogenesis, in
which the distracted segment and newly generated bone (termed regenerate) is
allowed to heal for 3 to 4 months. The distraction appliance is then removed, and
implants are usually placed at the time of distractor removal. Additional bone
augmentation may still be required. Horizontal distraction of the alveolus to
increase width followed by implant placement has also been completed
successfully.
Diagnostic Imaging and Virtual Treatment Planning
The increasing availability and use of computed tomography and cone-beam
computed tomography scanning, along with significant software advances, have
dramatically changed the way implant cases are planned from both surgical and
prosthetic standpoints. Cone-beam computed tomography scans with three-
dimensional reconstruction allow detailed visualization of the bony anatomy in all
three planes of space. Cross-sectional viewing of the bony anatomy allows detailed
analysis of all important anatomic structures, including ridge size and shape,
position of the maxillary sinus in relation to the ridge, and location of the inferior
7
 Dental Implantology
th
5 year Dr. Auday M. Al-Anee
alveolar nerve or adjacent tooth roots. Proprietary software that facilitates the
integration of the desired final prosthetic result with the underlying bony anatomy
is available.
By using computer technology to “virtually visualize” underlying bone anatomy
along with the planned final prosthetic result, the need for bone grafting, as well as
the position and angulation of implant placement can be planned with extreme
precision. By using rapid prototyping technology, a surgical guide can then be
created with laser polymerization of resin. Guide cylinders that exactly match the
size of surgical drills used for implant site preparation can be imbedded in the
surgical guide. The guide, which is securely fixed to either the maxilla or the
mandible, dictates the exact position, angulation, and depth of each implant. In
some cases, it is possible to place implants through the surgical guide, which can
provide an index for the internal or external retention configurations of the implant.
This allows the prosthetic provisional restoration to be constructed before surgery
and delivered immediately at the time of implant placement.
Computer-assisted surgical treatment planning has become prominent in medicine
and dentistry. The obvious next step is to implement computer-assisted surgery, or
surgical navigation, to ensure accuracy and efficiency as well as reproducible
outcomes. Surgical navigation has been used with positive outcomes in the hospital
setting for years. Adapting this technology for intraoral dental surgical purposes
has posed a number of new challenges. The primary concerns revolve around the
equipment necessary to execute intraoral navigation. Bulky handpieces and reliable
and reproducible calibration have been on the forefront of adapting this
technology. Dynamic navigation in implant dentistry is evolving and will continue
to become a key component in successful patient outcomes.
Zygomatic Implants
There are some situations where grafting of the sinus floor may not be feasible.
Such cases may include patients with compromised health or individuals who are
reluctant to undergo staged surgery requiring multiple surgeries and prolonged
treatment times. In these cases the use of a zygomatic implant can be considered.
The implant was originally developed in the early 1990s by Brånemark, with
several subsequent modifications. The implants are extremely long, ranging from
35 to 55 mm. The implants are placed intraorally, with exposure to the crest of the
alveolar ridge and the body of zygoma and visual access to the maxillary sinus.
After the membrane is reflected, the implant traverses the maxillary sinus, with the

8
 Dental Implantology
th
5 year Dr. Auday M. Al-Anee
tip engaging the body of the zygoma and the external hex fixture emerging in the
second premolar or first molar area of the maxilla. The portion of the implant
embedded just medial to the alveolar crest or zygomatic bone undergoes
osseointegration similar to other implants. The posterior zygomatic implants are
usually combined with four anterior implants, all supporting a fixed prosthesis.
Extraoral Implants
Recognizing the success of implants for oral applications, maxillofacial
prosthodontists and surgeons have expanded use of titanium fixtures to extraoral
application. Extraoral implants are currently used to anchor prosthetic ears, eyes,
and noses for patients with defects resulting from congenital conditions, trauma, or
pathologic conditions.