Implant lecture(mohammad algrhraisi).

DENTAL IMPLANT: AN OVERVIEW
BY
MOHAMMAD AL-GHRAISI
BDS,MSc
2019

• Functional loss
• Aesthetics
• Facial support and masticatory insufficiency
• Pronunciation and phonetics
• Eating insufficiency
• Impede normal contour and comfor

It Maintains Bone Volume.
Bone needs stimulation to maintain its form and
density.
• Loss of teeth leads to loss of width then height
of the
bone.
• After one year 25% of width and up to 4 mm of
height will be lost.
• • Preservation Of Adjacent teeth.
• • Natural Emergence Profile.
• • Increases stability and Retention.
• • Reduce Removable prosthesis size.

MEDICAL CONTRAINDICATION
1…ABSOLUTE CONTRAINDICATIONS
 Recent myocardial infarction
 Valvular prosthesis
 Severe renal disorder
 Uncontrolled diabetes
 Uncontrolled hypertension
 Generalized osteoporosis
 Chronic severe alcoholism
 Radiotherapy in progress
 Heavy smoking(20 cig. a day)

2. RELATIVE CONTRAINDICATIONS:
 Ridge dimensions are insufficient to accommodate proper
implant placement
 Habits such as‐
• Tobacco use
• Alcohol consumption
• Poor oral hygiene
• Bruxism
• Nail biting
• Pencil biting
• Tongue habits

PATIENT’S ATTITUDES:
Chief complaint
Expectations
Esthetic expectations
Desired functional results

Type of prosthesis
Bone quality
Number of implants
Implant length
Implant diameter
Position of implant(surgical guide).

 single implant prosthesis
 Implants supported fixed prosthesis
 implant supported overdenture prosthesis
Anterior
region
Posterior
region
Multi-unit
implant
Full arch
rehabilitaion
ALL ON 4
concept
Implant
supported
removable
overdenture
prosthesis
implant supported
complete overdenture
prosthesis

IMPLANTS SUPPORTED FIXED PROSTHESIS

The interview for the diagnostic and for scheduling the
treatment
 The surgical procedure
 The healing phase
 The prosthetic phase
 The follow-up phase and professional care.

RIDGE MORPHOLOGY OF EDENTULOUS REGION
Ridge morphology of the edentulous region gives an approximate idea
about underlying bone dimensions, positions, and angulations required for
implant placement, and also revealed the presence of any undercuts, etc

Role of available bone in
dental implant

ROLE OF AVAILABLE BONE IN DENTAL
IMPLANTS

ROLE OF AVAILABLE BONE IN DENTAL
IMPLANTS
• Misch and Judy classification of bone availability
Division A(abundant bone)
Bone in this category should be
 5mm or more in width
 12mm or more in height
 7mm or more in length
 Less than 30% in angulatio
 15mm or less in crown height

Division B(barely adequate)bone
 2.5-5mm in width
 12mm or more in height
 6mm or more in length
 Less than 20% in angulation
 15 mm or less in crown height

DIVISION C( COMPROMISED BONE)
Bone in division c catogory should be:
 0-0.25 mm in width(C-W bone)
 Less than 12mm in height(C-h bone)
 More than 30% in angulation (C-a bone)
 More than 15mm in crown height

DIVISION D
This is the bone with severe atrophy, and it represents
as basal bone loss, flat maxilla, and pencil-thin
mandible with more than 20mm crown height

OSSEOINTEGRATION
• Osseointegration is basically a union betwwen bone and
the implant surface.
• Greater levels of bone contact occur in cortical bone than
cancellous bone. So, bone with well-formed cortices and
dense trabeculation offer the greatest potential for hight
degree of bone to implant contact.

OSSEOINTEGRATION
Clinical evidence of successful osseointegration
 Implant is not mobile when tested clinically
 Implant is asymptomatic
 Stable crestal bone levels, annual rate of bone loss should be
less than 0.2mm after the first year in function
 Health soft tissue
 Absence of peri-implant radiolucency

METHODS USED TO ASSES IMPLANT STABILITY
 Radiographic analysis
 Percussion test
 periotest

IMPLANT SURFACE
 As general rule, roughened surfaces increase the bone-implant
contact(BIC) percentage during the initial bone healing process.
 Several research studies have shown that a roughnened titanium
implant surface improves bone anchoring compared to
conventionally machined titanium surfaces. So rough surface
facilitates migration of osteogenic cells to the implant surface for
de novo bone formation(contact osteogenesis)
 Osseointegration phenomenon was defined as direct contact
between living bone and functionally- loaded implant surface
without interposed soft tissue at the light microscope level

MACHINEDSMOOTH IMPLANT SURFACE
It was the most commonly used surface in the past.

SANDBLATED SURFACE
 Titanium metal implants are sandblasted, using agents such
as aluminium oxidealumina(al2o3), titanium dioxide(TiO2),
and calcium phosphate to increase surface rouphness
 The sandblasting allowing addition , proliferation ,
differentiation of the osteoblasts over the implant surface.

TITANIUM PLASMA SPRAY (TPS) SURFACE
The implant were prepared by spraying it by molten metal were increased
microscopic surface area approximately 10 times

ACID-ETCHED SURFACE
Acid-etching of titanium implants is performed using paths of
hydrochloric acid(HCL), nitric acid and sulphoric acid, were
produces microtexture implants surface which improves the
BIC percentage as well as reverse torque value of the
implants.

SANDBLASTED AND ACID_ETCHED SURFACE
Sandblasting to produce a final microtexture, followed by acid-
etching to produce a final microtexture surface. This surface
shows high BIC percentage .

HYDROXYAPATITE (HA) COATED SURFACE
Hydroxyapatite coated implants have shown roughness and
functional surface similar to TPS implants.
This surface show accelerate interficial bone formation.
HA shown higher success rates for implants used in low
density D4 bone.

SUBMERGED
TECHNIQUETHE TWO-STAGE
METHOD
•In this method,
•Two surgical procedures are carried out. The
•first surgery involves installing the implant
•into the bone, and cover screw level with the crestal
bone and mucoperiosteal flaps closed over the
implants and left to heal for several months

ADVANTAGES OF SUBMERGED PROTOCOL
• 1. Bone healing to the implant surface occurs in an environment free of
potential bacterial colonization and inflammation.
• 2. Epithelialization of the implant-bone interface is prevented.
• 3. The implants are protected from loading and micromovement that
could lead to failure of osseointegration and fibrous tissue
encapsulation.

THE ADVANTAGES OF THE ONE-STAGE METHOD INCLUDE:
The avoidance of a second surgical procedure;
The lack of a micro-gap between the implant and the
abutment at the alveolar bone crest level, resulting in a less
crestal bone resorption;
The prosthetic procedure is simplified and less chair time per
patient is required

SOFT TISSUE BIOTYPE
(A) Thin biotype, more prone to recession and muscle pull, (B) thick biotype, more resistant to
recession.

Fig 7.4 (A and B) A thick band of keratinized soft tissue regenerated with soft tissue
grafting during implant uncovery to minimize the chances of soft tissue recession
and peri-implantitis.

PAPILLA AT THE IMPLANT SITE (INTACT OR
FLATTENED)
Fig 7.5 Care should be taken to preserve intact papilla in the regions of high aesthetics. (A and B)
Papilla preservation incision should be planned in such cases to maintain the papillae for future implant
prosthesis. (C and D) Flattened papilla.

PERIODONTAL HEALTH OF ADJACENT TEETH
(A) Tooth adjacent to the future implant site showing deep periodontal pocket with purulent discharge
through a sinus. The infected pocket is treated first with scaling, curettage and antibiotics until it healed and
showed no active infection. (B and C) The healed periodontal osseous defect is exposed, cleaned, irrigated
with antibiotics and grafted simultaneous to implant placement at the adjacent site.

OPPOSING AND ADJACENT TEETH AT OCCLUSAL
POSITION
Fig 7.7 (A) Supra-erupted opposing tooth not only result in reduced inter-arch space but also cause
undue forces over the implant prosthesis during lateral excursive movements. (B and C) The drifting
of adjacent teeth results in reduced mesiodistal dimensions for the implant prosthesis.

TOBACCO CHEWING
Fig 7.8 (A) Implants if inserted in the patient with the tobacco chewing habit result in (B) recurrent soft
tissue infections under the implant prosthesis.

ORAL HYGIENE OF THE PATIENT
• Oral hygiene maintenance is mandatory to avoid any
infection to the inserted implants and also for their long-
term survival. Advanced periodontitis should be treated
before implant therapy. Scaling and root planing should
always be done before implant insertion. Preoperative oral
rinses with a 0.12% chlorhexidine digluconate solution has
been shown to significantly lower the incidence of
postimplantation infectious complications. A preoperative
30-s rinse is recommended, followed by twice daily rinses
for 2 weeks following surgery.

BRUXISM
• The problem of bruxism should be treated before placing implants, to
avoid post loading problems, such as the early wearing of the
prosthesis, ceramic fractures, component fractures, crestal bone
resorption, etc. (Fig 7.9A–D).

HISTORY OF DISEASED OR LOST TEETH
The history of tooth loss is very usful to evaluate the bony tissue
present at the planned implant site.
For such cases the dentist should plane for bone augmentation
procedures during and before the implant placement.
Traumatic
loss of tooth
Tooth loss
because
periodontal
infection
Teeth with
periapical
radiolucency

These radiographs give ideas about any
 Root remnants
 Mesiodistal dimensions of edentulous space
 Bone height available to insert implant
 Any curvature of adjacent teeth
 Any bone defect or undercuts
 Any periodontal or periapical lesion of adjacent teeth
 Distance from vital structures
Should keep in mined that the panoramic radiograph may show 10-
30% magnification of hard structure

IMPRESSION AND DIAGNOSTIC CAST
PREPARATION
Impression of both arches should be made and bite
registration to:
 To evaluate the patient opposing toothteeth , their overeruption ,
buccal and ligual inclination, drifting of adjacent teeth, ridge form, etc
 To fabricate a radiographic template(using radiographic or Ctscan),
which is used for accurate planning of the implant
 To fabricate the surgical stent for accurate implant placement
 For fabrication of the intrim prosthesis after implant insertion

CLINICAL PICTURES OF THE EDENTULOUS
AREA
These are used to record:
 The pr-clinical situation of the case
 Ridge morphology
 The width of keratinized soft tissue collar at the implant site
 The periodontal health of adjacent teeth
 Patient occlusion
 Any soft tissue lesion

BONE MAPPING
Bone mapping is done to evaluate the buccolingual bone
dimension at the edentulous site, which can be evaluate by
 Bone calliper
 CTscan

RADIOGRAPHIC TEMPLATE FABRICATION
An ideal provisional prosthesis is fabricated for the edentulous site
by setting the teeth in position and correct occlusion with opposing
dentition or prosthesis.
Either radioopaque teeth are used in template or radioopaque
material as gutta-percha were filled in the template at the
prosthetically accurate( desired implant site).
The template is accurately seated in patient mouth and patient send
to dental radiograph.
The radioopaque teeth or material is clearly visible in dental
radiograph and represent the ideal implant position.( prosthetically
guided implant insertion).

CT PLANNING
The dental CT scan gives an idea about
 Accurate three-dimensional measurement of available bone
 Bone density at implant site
 Bony ridge morphology
 Bone angulation
 Any osseous defect
 Volume of graft required

SURGICAL GUIDE FABRICATION
Implant insertion should be guided by the planned future prosthesis. So we
need to use the surgical guide.
There are different ways to fabricate the surgical guide
Manual surgical
guide
Computer-
assisted
surgical guide

COMPUTER-ASSISTED SURGICAL GUIDE

KEY POINTS OF TREATMENT PLANNING FOR
SUCCESSFUL IMPLANT THERAPY
Implant diameter selection
Implant diameter has been conventionally selected according to
the bone dimension available at edentulous site.
The ideal implant diameter should be chosen to
• bear occlusal and horizontal forces,
• Achieve an aesthetic emergence profile
• Avoid screw loosening
• Facilitate oral hygiene

2. Implant diameter
According to the
diameter, implants may be classified as mini when
diameter is ≤2.7 mm; narrow when the diameter is >2.7
mm but ≤3.75 mm; regular when it ranges from 3.75−5
mm; and wide when the diameter is >5 mm.

IMPLANT DIAMETER SELECTION
If inadequate bone dimensions are available
Grafted to regenerate
new bone
dimensions for the
placement of an
ideal diameter of
implant
More number of narrow
diameter of implant
should be inserted and
splinted together

IMPLANT DIAMETER SELECTION
• Advantages of wide diameter implants
 Increase bone implant surface contact area
 Minimizes the cantilevered offset forces
 Minimizes implant component fracture
 Improved emergence profile
 Decrease screw loosening

IMPLANT LENGTH SELECTION
Using a longer implant increases initial stability and bone
implant interface.

IMPLANT DESIGN SELECTION
 The internal connection implant is preferred over the external
connection implants
 Implants with deeper threads are preferred in low-density bone to
achieve adequate primary stability
 Implant with shallow threads should be prefferred in high-density bone
to avoid pressure necrosis of bone
 The deep threads implants should be chosen with immediate implant to
achieve primary stability

87
double threads
smooth and tight fixation
Biological Thread
Rich bone housing design
S.L.A. Surface
Successful early loading
Taper portion
Bone expansion
& Initial stability
Parallel portion
Distribute
stress evenly
Taper portion
Easy Installation
Fixture Design
Cutting edge
3blade self tapping design
Para
Tape
Easy I

Internal connection
•Advantages of the internal connection
Less screw loosening
Better esthetics
Improved microbial seal
Better joint strength
More platform switch option

PLATFORM SWITCHING
Platform switching is the use of smaller diameter abutments on wider
diameter implants. Platform switching implants with a conical implant-
abutment connection provide better results in terms of abutment fit,
stability, and seal performance, resulting in less horizontal and vertical
crestal bone loss, compared to implants restored with a matched implant-
abutment design.
Platform switching implants may be of importance in areas of aesthetic
concern, reducing the safety distance between the nearest teeth/implants,
as well as the risk of an exposed metal implant shoulder.

Internal connection
Disadvantages of internal connection
•The weakest link is the bone rather than the
•retaining prosthetic screw.

CEMENT RETAINED VS SCREW RETAINED
vs
Advantages of cement
retained
1. Retrievable (soft access
cement
2. Ease of splinting implant
3. More passive casting
4. Easier correction of non
passive casting
5. Improve force direction of
load
6. Enhance esthetic
7. Reduce fracture of
components
8. Reduce cost
9. Less chair time
Advantages of screw
retained
1. Low –profile retention
2. Reduce moment force
of overdenture
3. Reduce risk of residual
cement
4. Splinting nonparallel
implant
5. Easy
• Safe
• Efficient
• Retrievable

BONE ANGULATION
Bone angulation should be correlated with the direction of the future
implant prosthesis.

DISTANCE BETWEEN TWO ADJACENT
IMPLANTS

DISTANCE BETWEEN IMPLANT AND
ADJACENT TOOTH

ROOT INCLINATION OF ADJACENT TEETH
The most important areas of concern are the maxillary and
mandibular canine regions.
The maxillary canine often shows the distal inclination of it is
root
While
The mandibular canine shows the mesial inclination of it is
root.

CONNECTING IMPLANT PROSTHESIS WITH
ADJACENT TOOTHTEETH
The natural tooth has periodontal ligaments, it shows more
degree of movement within bone in comparison to
osseointegrated implant . Hence , connecting an implant with
the natural tooth results in micromovement of the implant
during function as well as crestal bone resorption .

IMPLANT DISTANCE FROM THE MANDIBULAR
CANAL

IMPLANT PROSTHESIS OCCLUSION (OCCLUSAL
DIMENSIONS AND CUSPAL INCLINATIONS):
 The implant prosthesis for premolar and molars should be fabricated
with narrow buccolingual occlusal table to centralize most of the
occlusal forces axial to the implant body and minimize the offset
occlusal forces on the prosthesis that may cause crestal bone
resorption
 The implant prosthesis also should have low cuspal height to avoid the
tensile forces on the ridge crest during lateral excursive movement of
the jaw

MESIODISTAL DIMENSION OF THE
EDENTULOUS MOLAR SITE
Carl E Mish advice a protocol for replacement of a molar which is as
follows:
 If the mesiodistal dimension of a missing molar space is less
than 11mm, a regular diameter implant 4mm can be inserted at
midpoint.
 If the mesiodistal dimension of a missing molar space is
between 11&13mm , either wide implant 5-6mm is inserted at
midpoint or two narrow diameter implant were placed to replace
molar.
 If this dimension is more than 13mm , two regular diameter
implants 4mm should be used to replaced molar.

Improper labiolingual or mesiodistal positioning leadin to
prosthetic, biomechanic, esthetics and hygienic problems

CROWN HEIGHT SPACE
The crown height space is measured from the occlusal plane to the
bone level.
 A minimum 8mm of crown height space is required for single
unit cement retained ceramic restoration.
 If crown height space is less than 8mm, the screw retained
prosthesis should be preferred over the cement retained one.

CROWN HEIGHT SPACE
Excessive crown height space
Problems of excessive crown height space:
Increase
stress on
implant
Heavy
weight in
the
prosthesis
Implant
component
fracture
Screw
loosening

CROWN HEIGHT SPACE
• Excessive crown height space
Management
 Longer implant used to minimize crown –implant ratio
 More number of implant should be used
 Regular or wide implant should be used
 Cantilevers should be avoided
 Multible implants should be splinted together
 Vertical bone augmentation should be done to increase bone height

CROWN HEIGHT SPACE
Reduce crown height space
problems
Compromise
retention of
cement-
retained fixed
prosthesis
Inadequate
space for
occlusal
ceramic layer
build-up
Prosthesis
fracture,deslo
dgement

MANAGEMENT
 Osteoplasty during implant insertion to increase the crown
height space
 Wider implant should be used
 Minimize offset forces on the prosthesis
 High- strenght luting cement should be used
 The screw retained prosthesis should be preferred over the
cement –retained prosthesis
 Multiple implants should be splinted together to achieve the
adequate retention for the prosthesis

)CANTILEVERING OF IMPLANT PROSTHESIS
(APSPREAD)
If occlusal forces are more centralized along the body of the
implant , the implant transfer these forces to the strong basal
bone
If axial or offset forces are exerted on the implant, it transfers
these forces to the ridge crest ridge resorption
•More the length of the cantilever , greater the additional
force placed on the prosthesis abutments

A-P SPREAD
•• The anteroposterior distance (A-P spread) of
implants is measured from the distal of the last
implants to the mid position of the most anterior
implant.
•• Because these splinted implants form an arch,
the cantilever may extend up to 2.5 times the A-P
distance (when patient force factors are low and
bone density is good).

NUMBERS AND POSITIONS OF IMPLANTS TO
RESTORE THE EDENTULOUS MAXILLA, WITH
OVERDENTURE

NUMBERS AND POSITIONS OF IMPLANTS TO
RESTORE EDENTULOUS MANDIBLE WITH
OVERDENTURE

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