37 Dental implants

Introduction Table 37.1 Osseointegrated dental implants

Dental implants are now increasingly used to attach
Osseointegration
crowns, bridges or dentures by anchorage to bone. Extra- Indications for implant treatment
oral implants are also available for attaching facial Patient selection
prostheses such as artificial ears or noses, and for bone Treatment planning
anchored hearing aids. Surgical technique
Placement of implants requires careful patient selection Augmentation of bone
Complications
and treatment planning. Although the surgical techniques Success rates
are straightforward, they are exacting and practitioners
should only embark on implant treatment after appropriate
training and experience. contact between the implant surface and bone without
any intervening connective tissue layer. It is, in fact, an
ankylosis of implant to bone and some prefer the term
Types of implant 'functional ankylosis'. The bone does not recognise the
implant as a foreign body, which becomes, in effect, part
Early implants were unreliable because the attachment to
of the bone. Thus an osseointegrated implant forms a
bone was by a layer of connective tissue. A variety of
direct bone anchorage for a prosthesis.
pins, screws and blades were tried but epithelial down-
Osseointegration is therefore a prerequisite to success-
growth frequently led to rejection. The resulting loss of
ful implant placement and a consideration of the require-
alveolar bone led to an even more difficult restorative
ments for this is followed by a description of the indications
problem.
for implant placement in dentistry. Discussion of patient
Subperiosteal implants were less damaging but
selection and treatment planning will be followed by a
required a general anaesthetic to expose the bone surface
description of the surgical techniques involved in implant
for impression taking. Chrome-cobalt frames were con-
placement including augmentation techniques, compli-
structed in the laboratory and a further anaesthetic was
cations and a consideration of success rates (Table 37.1).
then required for insertion. They were often in function
for many years but epithelial downgrowth usually resulted
in failure. Removal of failed implants was difficult due
extensive scar tissue.
Osseointegration
Transmandibular implants appeared to have some The requirements for successful osseointegration of an
advantages but an extraoral incision was required and the implant are listed in Table 37.2. Suitable implant materials
surgical technique was demanding. They were obviously are discussed below.
unsuitable for routine use as they required specialist
expertise and hospital facilities.
Implant materials
The progression to modern implantology followed the
discovery of osseointegration, with the predictable Ideally, an implant should be non-toxic, biocompatible,
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success of titanium implants. Osseointegration implies strong and aesthetic.
 gas at high temperature in an electric arc. Plasma-sprayed
Table 37.2 Requirements for osseointegration
implants have a much greater surface area and mechanical
Suitable implant material resistance to rotational forces. Abrasion of the surface
Minimal surgical trauma with titanium pellets or grit blasting and acid etching
Primary implant stability may also achieve similar effects. Some workers claim
Adequate bone volume and quality
that these surface modifications promote a chemical and
Delayed loading (healing phase)
mechanical attachment to bone. Rough surfaces exposed
to the mouth will be difficult to keep clean and plaque
Metals such as nickel and chromium used in stainless formation will result in peri-implant disease. Transmucosal
steel are corroded in living tissue and taken into the blood- elements and abutments are therefore made smooth. A
stream. There is concern about possible neurotoxicity. 'gingival' cuff attachment is achieved by reorientation of
Titanium is also absorbed and may be detected in tissues connective tissue fibres and possibly by adhesion of
at very low concentrations, but there is no evidence of epithelial cells.
toxicity.
Implant materials can be biotolerated, bioinert or
Ceramic
bioactive. Stainless steel, chrome cobalt and other alloys
are tolerated by bone but are linked by a connective tissue Ceramic implants had good biological and aesthetic
layer rather than an intimate bond. Titanium implants properties but lacked mechanical strength. In practice the
make direct contact with bone but are regarded as bioinert incidence of implant fracture was unacceptable and they
because there is no chemical bond. Bioactive materials have been discontinued. It is possible that better ceramics
such as calcium phosphate and hydroxyapatite allow a true will be developed.
chemical bond to develop as the bone surface remodels.
The material should be able to withstand occlusal forces
Hydroxyapatite
and be capable of accurate machining into cylinders with
screw threads for initial stability in bone, and with suit- Hydroxyapatite can be used as a coating on titanium
able abutment connections. Unfortunately, a bioactive implants because it is osteoinductive. It enhances, and
material with adequate mechanical properties has not yet reduces the time for, osseointegration. It is also used in
been developed. particle or block form to augment bone for placement of
Surface characteristics can modify the properties of implants. It does have mechanical weakness and disrup-
the material. Correct pore size is important in osseo- tion of the surface occurs in function, although these
integration of ceramics. Surface roughness may affect the microfractures do not seem to result in loss of implants.
reaction of tissues to implants enhancing osseointegration Fractures can also occur at the interface between
as well as increasing the surface area in contact with hydroxyapatite and titanium.
bone.
Implant system
Titanium
Many implant systems are available and many factors
Titanium is the best material available at present. It is a need to be considered when making a choice. These are
highly reactive metal that oxidises in the atmosphere to listed in Table 37.3.
form an inert surface layer of titanium oxide. It has good
mechanical properties and can be machined. Implant
Surgical principles
fractures can occur but these are minimised by careful
implant design and avoidance of a traumatic occlusion. A Initially an implant bed must be prepared by drilling a
disadvantage of titanium is its grey colour, which may be hole in the bone to receive the implant. It is essential to
visible at crown margins if there is recession and may minimise tissue damage when preparing the implant bed.
discolour thin mucosa. The surface can be polished and Mucoperiosteal flaps should be well designed, carefully
anodised and surface roughness can be achieved by reflected and gently retracted, so that healing is optimal.
addition or subtraction processes. In plasma coating, Healthy soft tissue cover enhances osseointegration by
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titanium powder is sprayed onto the implant as an inert providing a barrier to infection and restoration of blood
 Table 37.3 Criteria affecting choice of implant Table 37.4 Bone drilling for osseointegration
system
Use sharp drills (single or limited use)
Use commercially pure titanium Use purpose designed drills
Components proven to withstand masticatory load Use drills of smaller diameters first, rather than one-
Physiological response of bone when loaded stage cutting
One- or two-stage system Use slow drill speeds (<2000 rpm)
Type of surface, i.e. plain, plasma sprayed, roughened Use cooling with copious chilled saline
or hydroxyapatite coated Avoid clogging of drill channels - repeated withdrawal
Plain cylinder, or threaded ± self-tapping Thread tapping or self-tapping systems are available
Diameter and length
Efficiency of drill system
Immediate or delayed loading
Suitability of abutments Table 37.5 Methods of improving implant
success in the maxilla
Use additional implants to share load
Use connecting bars for bracing
supply. With transmucosal systems, soft tissue is sutured
Use maximum length of implant
around the implant neck and a good seal is even more Consider augmentation of ridge bone
important. Consider sinus lift to extend available ridge
Bone preparation is carried out with the minimum Reduce occlusal table and eliminate traumatic occlusion
heat production so that, as far as possible, the osteocytes Allow more time for osseointegration
near the bone surface remain vital. If there is bone
damage the inflammatory reaction will produce a fibrous
repair resulting in a connective tissue layer between The pattern of bone resorption and anatomical
implant and bone rather than osseointegration. structures in the maxilla also cause problems. Resorption
The requirements that -must be taken into account causes bone loss from the anterior and crestal surfaces,
when drilling bone to receive an implant are listed in often leaving a narrow ridge in a retruded and high
Table 37.4. position. Thus there is less bone and the implants have to
be placed in a poor position. The superstructures may
then be placed in a compromised position. The occlusal
Primary implant stability
load on the implants may therefore be beyond
The implant bed should be prepared accurately to con- physiological tolerances.
form to the shape of the implant, so that there is maximum Implants can still successfully be placed in the
contact with healthy bone. This good congruence also maxilla if allowance is made to avoid exceeding the
results in primary implant stability, which is essential above limitations by the methods listed in Table 37.5.
during the healing phase. Resorption in the mandible does not alter the antero-
Screw threads are often used as they increase primary posterior implant position but there can be severe loss of
stability, enhance resistance to occlusal forces and bone height. The alveolar bone has often been completely
increase surface area. resorbed and there is a pencil-thin mandible. Augmentation
is rarely required, even in this situation, and two implants
may be sufficient to stabilise a lower denture. This is
Bone quality and quantity
fortunate, as denture instability is more of a problem in
Blood supply is essential for bone vitality so the maxilla the mandible.
might be thought to be better suited for implant Blood supply may be compromised by radiotherapy
placement. In fact, there is a significantly better success but, although this causes more failures in the mandible,
rate in the mandible, which is likely to have a poorer there is still a reasonable success rate. In the maxilla
blood supply especially in the older edentulous patient. It there are many more failures after radiotherapy. A course
seems, therefore, that a firmer bone structure is an of preoperative and postoperative hyperbaric oxygen
advantage. The cortical plate in the maxilla is often thin therapy, if available, may improve success in the maxilla
294
or absent and the cancellous bone is crumbly. but is not usually needed in the mandible.
 Table 37.6 Classification of bone quality Table 37.7 Indications for implant treatment

I Cortical bone predominant Difficult edentulous cases

II Dense cancellous bone and thick cortical bone Long span bridges
III Dense cancellous bone and thin cortical bone Free end saddles
IV Porous cancellous bone and thin cortical bone Single tooth replacement
Special indications

The quality of bone available is also important and

this can be assessed using the classification listed in
restores function and confidence. An implant-supported
Table 37.6.
removable denture is a simple, cheaper and effective
option. Two implants with stud attachments or a bar can
Healing phase be sufficient to stabilise a denture, which is then mainly
tissue borne. Implants are always placed between the
It is a fundamental requirement that undue loading is
mental foramina in edentulous cases.
avoided until osseointegration has occurred. This is one
Retention problems occur in the maxilla, although
of the main differences compared to previous implant
less frequently because the hard palate gives better sup-
practice where there was immediate loading and osseo-
port and retention for a conventional denture. Resorption
integration rarely occurred.
can lead to a flabby ridge and retrusion. Implants placed
In the mandible, 3 or 4 months are required for
in the anterior maxilla will aid retention and stability but
osseointegration, whereas in the maxilla 6 months is
poor bone quality requires placement of as many implants
allowed. These rules have been relaxed in the anterior
as possible and a bar may be required for bracing.
mandible only. If bone quality is good, depth is adequate
Patients who are unable to tolerate a denture, due to
and four or five (or possibly fewer) implants are placed,
gagging, or who are unwilling to wear a removable
the superstructure may be fitted immediately. Theoreti-
appliance, can benefit from an implant-born bridge,
cally, function encourages bone formation and there is
although the lip will not be as well supported as with a
some evidence that controlled loading could be
denture flange. This problem should be explained to the
beneficial. This is difficult to control in practice at
patient, who may then prefer a conventional denture.
present.
If the patient decides on implant treatment, ridge
augmentation may be necessary, especially in the
maxilla. The available bone can also be increased by a
Indications for implant sinus lift where a bone graft or synthetic material is
placed in the maxillary antrum.
treatment
The availability of implants has expanded treatment
Long span bridges
options for a number of restorative problems highlighted
in Table 37.7. Implants can be used where the span is too long for a
conventional bridge or when abutment teeth are com-
promised by bone loss, short roots or extensive
Difficult edentulous cases
restoration.
Poor retention of a mandibular prosthesis not only In the maxilla, there may be limiting factors such as
interferes with eating but also inhibits social contact, as inadequate or poor quality bone. Resorption may result
patients are afraid that the denture will dislodge in speech in an unfavourable position or angulation of the implant,
or mastication. The attached mucosal ridge may be little necessitating a long clinical crown or placement of the
more than 1 mm wide and the sulcus mucosa is prone to restoration well in front of the ridge. These aesthetic
pain or ulceration. Severe resorption often results in problems are noticeable with a short upper lip. Lip con-
prominent genial tubercles or exteriorisation of the tour may be not be as good as that obtained by a denture
mental nerves so that provision of a comfortable denture flange. Augmentation should be considered as in
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is impossible. An implant-supported fixed prosthesis edentulous cases.
 In the mandible, the pattern of bone resorption is less
Table 37.8 Special indications for implant
of a problem and the main constraint is the proximity of treatment
the inferior alveolar or mental nerves.
Wind instrument players or singers
Denture intolerance due to gagging
Free end saddles Psychological aversion to dentures
Xerostomia, e.g. Sjogren's syndrome
Replacement of mandibular molars is difficult with con- Physical disability (e.g. cerebral palsy, stroke or
ventional dentures. There is a risk of mental anaesthesia myasthenia gravis)
when placing implants in the posterior mandible so it is
essential to allow a good safety margin when calculating
implant length. Drill tips do not conform exactly to the Table 37.9 Medical problems compromising
shape of the implant so allowance must be made for implant success
the additional depth of the implant bed. The maxillary
Cardiac disease
antrum limits implant placement in the posterior maxilla.
Haematological disease
Immunological disease
Single tooth replacement Bone disorders
Other systemic disease
It can be simple and cost effective to replace an incisor Oral disease
tooth with an implant when there is adequate bone. If
there is a diastema, the difficulties in construction of an
adhesive bridge or partial denture are avoided. Also, Medical history
preparation of adjacent teeth is avoided and there are no A detailed consideration of the patient's medical history
denture clasps. Unfortunately, the pattern of bone is essential because several conditions can compromise
resorption can result in an unfavourable path of implant implant success by interfering with healing, or increasing
emergence in the maxilla (especially if there is a history the risk of infection (Table 37.9).
of previous replantation or transplantation of a canine or
incisor). If there is crowding, the nasopalatine canal can
be large enough to prevent implant placement. This can Cardiac disease
sometimes be overcome by restoration of ridge form by Severe cardiac problems can present risk but many patients
bone augmentation. with mild disease can benefit from implants. Simple
questions about exercise tolerance give an indication of
Special indications the patient's ability to withstand a surgical procedure.
Implant failure is more likely in a patient with severe
Implants may also be indicated under special debilitation. Patients who are at risk of endocarditis may
circumstances that are not dental in nature. These are be suitable but regular monitoring and radiographs are
listed in Table 37.8. advisable, and any failing implant should be removed
without delay. Implants are contraindicated in patients
who have had a recent myocardial infarct, a valve replace-
Patient selection ment, are in cardiac failure or who have had previous
Patient selection is important when planning implant bacterial endocarditis.
treatment to avoid a poor outcome and complications.
Haematological disease
Clinical history and examination
Treated or mild anaemias should not prevent implant
The clinical history and examination will reveal the treatment. Patients with haemophilia and other signifi-
patient's caries and periodontal disease experience. cant factor deficiencies would not normally be suitable.
Patient compliance can be an important indication of Warfarin therapy is a relative contraindication, but
suitability. It is also important to ascertain the patient's surgery may be possible in selected cases with careful
296
expectations of treatment. monitoring of the international normalized ratio (INR).
Immunological problems Oral disease
Prolonged corticosteroid therapy can present a risk but It is important to ensure that the patient has a stable
the patient can be given steroid cover. Implant survival periodontal condition and low caries rate at the time of
may be reduced in patients on corticosteroids and this assessment, although many patients require implant
should be balanced against the potential benefit to the treatment as a result of previous neglect. Mucosal
patient. Patients on chemotherapy and those with severe disorders should be eliminated as far as possible. Bone
immune deficiency should not be considered. Drug quality and availability should be assessed (Table 37.6).
addiction depresses immune responses and implies poor
compliance. Smoking has an adverse effect on implant
survival and patients should be strongly advised to cease. Treatment planning
Smoking most probably reduces the success rate by
Apart from appropriate patient selection, successful
significantly reducing the bony blood supply, especially
treatment planning requires consideration of the avail-
to the mandible.
able bone and space within the mouth (Table 37.10) and
the associated anatomical structures (Table 37.11). Treat-
Bone disorders ment planning also needs to be informed by appropriate
radiographic examination and examination of articulated
Most bone diseases are a contraindication. Osteoporosis
study casts.
is especially common in older females but the jaws are
less affected and implants can still be successfully
placed. Radiographic examination
If a patient has undergone radiotherapy there will be a
Conventional radiography, including an orthpantomo-
poor success rate in the maxilla although hyperbaric
graph (OPT) and periapical or lateral views where
oxygen (HBO) has been used with some success. Fewer
relevant, is necessary. The OPT is most useful because it
problems are encountered in the mandible and HBO is
indicates vertical bone height and the position of all
not essential.
relevant bone cavities and nerve canals. It is important to
make allowance for distortion and magnification when
Other systemic diseases using an OPT. Transparent overlays are available but
more accuracy can be obtained by inserting a base plate
Many other medical conditions, such as renal or liver
with standard metal balls or strips of gutta percha over
disease, can compromise treatment and consultation with
the planned implant positions before taking the radio-
the patient's physician is advisable if in doubt. Indi-
graph. This latter method enables exact calculation of
viduals with well-controlled diabetes can be accepted,
available bone when implants are to be placed close to
although they have a greater risk of peri-implant disease.
the inferior alveolar nerve or other important structures.
Patients with psychiatric disorders should be accepted
Serial tomograms or computerised tomography (CT)
with caution, especially if they attribute their problems to
scans may also be used where detailed mapping of
dental disorders.
available bone and anatomical structures is required. CT
scans are not always readily available and they involve a

Table 37.10 Available bone and space for

implants Table 37.11 Anatomical structures important in
implant treatment planning
6- or 7-mm ridge width (i.e. implant diameter + 2 mm)
Proximity of adjacent teeth or foramina (incisive, mental) Maxilla
Adequate distance between implants for superstructure floor of nose
Depth of bone maxillary antrum
Safety margin for inferior alveolar nerve, floor of nose nasopalatine foramen
and maxillary antrum Mandible
Undercuts inferior alveolar nerve
Sufficient intermaxillary space for superstructure mental nerve 297
 much higher radiation dose. Scatter due to metal from the crest so that the suture line was not directly over
restorations can render the image unusable. CT images the implant. This was technically more difficult and is
can be very helpful but can be disappointing unless the now less popular because of the risk of haematoma
radiologist is familiar with dental requirements and formation or flap necrosis.
software. When augmentation procedures are planned, a bevelled
Magnetic resonance imaging (MRI) is becoming flap is taken so that mucosal cover of the membrane or
more readily available. It has no radiation dose and the graft is achieved. A bevelled flap taken from the palatal
only known hazard is with ferrous metals in the magnetic aspect can also be used to improve the bulk of buccal
field. It is likely to replace CT scanning and - eventually interdental papilla when uncovering a buried implant at
- most other X-ray investigations. New machines will be the second stage.
less likely to induce claustrophobia and noise levels are
now significantly reduced.
Bone drilling
Purpose-made sharp drills are essential. Many manu-
Study casts
facturers advise single use and supply prepacked sterile
Study casts are invaluable for demonstrating treatment drill kits. It is essential to have an accurate indication of
options. Duplicates can be used for a diagnostic wax-up drill speed so that overheating is avoided by keeping
so that tooth position can be planned. A template can below 2000 rpm. Thermal damage is also minimised by
then be constructed with indicator holes drilled as an aid incremental drill stages up to the final diameter. Thread
to the surgeon, so that implants are placed in the optimum tapping, where required, may be hand driven or by very
position at operation. slow drilling, preferably using a drill with a torque con-
troller. Copious irrigation with chilled saline solution is
essential. Drills must be withdrawn frequently to allow
Other treatment options
cooling and prevent clogging of the drill channels. It is
After considering the factors relating to patient selection important to maintain drill direction, or the implant bed
and treatment planning, restorative options should be will be inaccurate.
considered (Table 37.12). Countersinking is used where the system requires the
cover screw to be buried or where the transmucosal
element is to be submerged to improve aesthetics.
Surgical technique
Flap design Insertion
Mucoperiosteal flaps are usually taken along the crest of Decontaminated and sterilised implants are individually
the ridge. Relieving incisions may be short, as it is not packed in vials. Titanium forceps are used if handling of
usually necessary to expose all the alveolar bone. If there the implant is required, but this is not normally necessary
are adjacent teeth it may be necessary to release the due to the design of manufacturer's delivery system. A
interdental papilla. Flaps should be handled carefully as fixture mount may be included in the package or attached
poor healing could compromise osseointegration. by the operator.
With two-stage implants where the implant is buried, The implant should be placed with as little con-
it used to be common practice to keep the incision away tamination as possible. Good flap retraction will reduce
contamination by saliva and epithelial surfaces. The
method of insertion varies but most implants are screwed
Table 37.12 Treatment options in either by hand or using a drill with a torque controller.
Removable partial denture
Irrigation is used to prevent overheating. Excessive force
Fixed bridge should not be used because heat will be generated, and
Complete denture there is also a danger of damage to the implant or cold
Implant-supported denture welding it onto the fixture mount.
Implant-supported bridge A cover screw is placed and the soft tissues are sutured
298 No prosthesis
over or around the fixture according to the system in use.
With two-stage systems, where the implant and cover Onlay grafts
screw are covered by mucosa, it is important to ensure
Blocks of bone may be used for extensive defects.
that the cover screw is seated properly, as soft tissue or
Cortical bone taken from the patient's iliac crest or
bone formation below the cover screw can be difficult to
calvarium is preferred but harvest involves major surgery
remove from the implant face at the second stage.
and the risk of donor site morbidity. Implants are placed
some months later when the graft has taken.
Abutment connection Immediate placement is also advocated, as early
loading may reduce resorption and the patient is spared a
Two-stage implants have to be uncovered to allow abut-
second operation. However, there may be an increased
ment placement. This is done through a small incision on
risk of loss of fixtures and bone due to infection.
the crest of the ridge or by removing a circle of mucosa
A reliable substitute for autologous block bone is still
using a punch. Bone may have grown over the cover
awaited.
screw and this is removed using the manufacturer's bone
mill. Instruments are also available to remove any bone
that has formed on the implant face because of a loose Guided bone regeneration
cover screw. The implant face must not be damaged Healing by osteoblasts produces bone but, when a blood
during bone removal as the junction with the abutment clot is organised by fibroblasts, collagen formation is
is accurately machined. A portal of entry for micro- predominant and scar tissue is formed. When a suitable
organisms would cause problems with infection later. membrane is placed over bone, however, fibroblasts are
A suitable abutment is chosen and screwed in, taking excluded and angiogenesis and osteogenesis occur in the
care that it is seated correctly and avoiding crossed cavity below. This is the basis of guided bone
threads. Selection of a suitable abutment at this stage can regeneration.
be difficult because the soft tissue level will vary as the Membranes can be non-resorbable (e.g. polytetra-
mucosal cuff matures. Alternatively, a healing abutment fluorethylene) or resorbable (e.g. collagen). The shape of
can be placed and the final abutment is selected once the the cavity can be maintained by using a reinforced mem-
soft tissues have healed. brane. Alternatively, the membrane can be supported
with bone, bone substitute or a mixture of both. Small
steel posts may also be used as supports. The periphery
Augmentation of bone of the membrane is stabilised by screws or pins, which
When there is insufficient width or height of bone it may can also be resorbable. Recent developments with the use
be possible to gain additional bone either before or at the of bone morphogenic proteins may revolutionise bone
time of implant placement. augmentation in the future.
Various methods of bone augmentation can be used,
including onlay grafts, guided bone regeneration, sinus Sinus lift procedure
lift procedures or ridge expansion. Bone graft materials
There is often insufficient bone height in the posterior
may be in block or granular form (Table 37.13).
maxilla due to bone resorption and the presence of the
maxillary antrum. Onlay bone grafts are prone to failure
and may be unsuitable due to lack of intermaxillary
space. The sinus lift procedure creates additional alveolar
Table 37.13 Bone graft materials
bone height within the antral space.
Autograft: patient's own bone, e.g. iliac crest, tibia or The antral lining is exposed by removing a window of
intraoral bone on the buccal aspect via a buccal mucoperiosteal
Allograft: human donor (not used due to risk of cross-
flap. The antral lining is carefully elevated intact and is
infection)
Xenograft: calcified matrix derived from biological supported by bone-grafting material. It is also possible to
material, e.g. bovine bone or coral (no risk of cross- leave the bony window attached to the antral lining and
infection due to removal of protein?) support both with graft material or implants. Immediate
Synthetic material: e.g. hydroxyapatite, tricalcium implant placement is only advised if there is sufficient
phosphate, glass 299
bone for primary implant stability (about 6 mm in height).
 An alternative is to approach the antral floor using
Table 37.14 Criteria for evaluation of success
osteotomes to enlarge a bur hole on the crest of the ridge.
The antral lining can then be lifted and supported by Patient satisfaction
bone graft material. When there is sufficient bone for Survival
primary implant stability the lining can be lifted through Suitable position
Mobility
an implant preparation. If the preparation is stopped just
Amount of bone loss
short of the antral floor the cortical plate can be tapped Health of adjacent soft tissues - pocketing and
upwards with the lining. The cortical plate and the inflammation
implant then provide support for the lining. Infections or radiographic evidence of peri-implant bone
pathology
Operative complications e.g. damage to nerves or
Ridge expansion adjacent teeth

Where there is sufficient bone depth but the ridge is too

narrow, the implant bed may be prepared by bone
expansion, provided that there is a cancellous layer
between the cortical plates. The crest of the ridge is
exposed leaving the rest of the alveolar bone attached to
mucoperiosteum. The ridge is widened by D-shaped and Table 37.15 Complications of implant treatment
round osteotomes between the cortical plates prior to
drilling. Intraoperative
implant in poor position
damage to mucosa and adjacent teeth
bone damage, i.e. lateral perforation, fracture of
Success rates alveolar bone or mandibular fracture
perforation into adjacent areas, e.g. lower border of
The patient's appreciation is a very good indicator of mandible, nasal cavity or maxillary antrum
success but objective criteria are required to monitor the nerve damage, e.g. inferior alveolar nerve
effectiveness of osseointegrated implants (Table 37.14). loose implant due to incorrect drilling
Various criteria have been suggested but the most reliable contamination of implant or bone
way to obtain comparable data is to record removal rates. implant damage, e.g. crossed thread or surface defect
primary haemorrhage - especially floor of mouth,
Cumulative survival rates are based on an actuarial possible airway compromise
calculation that allows for the fact that implants in a Postoperative
series will have been present for differing times. It is pain
reasonable to expect that, in the maxilla, 90% of implants swelling
will survive for 10 years. In the mandible a 95% 10-year reactionary or secondary haemorrhage
infection of peri-implant soft tissue or bone
survival is expected. exposed or loose cover screws
A number of adverse events may complicate implant Late
placement (Table 37.15). Avoidance of these compli- mucosal recession
cations can only be achieved by careful planning and an bone resorption
exacting surgical technique based on sound training and mobility
implant fracture
experience.

300