Dental implantology

4th stage
Dr. Muntassir Agha
FIBMS, BDS
2024
Dental implant:
It is a material that substitutes
the root or roots or permanent
tooth or teeth that had been lost
by many factors.
The partially or completely
edentulous patient can now
undergo replacement with xed
or removable prosthetic options
with comfort, function and
con dence.
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Historical view:

Blade vents
Press- t cylindrical
Subperiosteally frame that t on the surface of the bone
Transmandibular in which the operators used rods
through the anterior part of the bone of the mandible.
These designs are no longer used.
The most endosseous implants have a cylindrical or
tapered, screw shaped/threaded design.
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Blade vents
Press- t cylindrical
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Transmandibular implants
 The most endosseous implants have a cylindrical or
tapered, screw shaped/threaded design.

Threaded implant design is

preferred because it engages
bone well and is able to n achieve
good primary stabilization.

The use of tapered implant

design has been advocated
because it requires less space in
the apical region so it is suitable
in the area where there is labial
concavity or newly extraction
sockets.
 Osteointegration
Osteointegration: it is the
direct structural and
functional connection between
organized, living bone and the
surface of load bearing implant
( xture) without intervening
soft tissues between them.
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 Clinically it is de ned
as: asymptomatic rigid
xation of an
alloplastic material
(implant) in bone with
the ability to
withstand the occlusal
force.
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Factors affect Osteointegration:
1. Abiocompatable material, Titanium
2. A traumatic surgery: heat production,
suitable a traumatic surgery.
3. Initial stability and placement of implant
with intimate contact with bone.
4. Immobility of the implant; depend on
volume and quantity of bone and length
and diameter of implant xture.
Bone quantities (type), the most perfect
implant start at cortical and end in cortical.
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The xture material:
The face of the implant xture has some property to
achieve good Osteointegration.
At the molecular level, modi ed implant surfaces increase
adsorption of serum protein, mineral ions, and cytokines;
this subsequently promotes cellular migration and
attachments. Also the type of the surface aids in the
retention of brin clot, so providing a pathway for
migration of the differentiating osteogenic cells to reach
the implant surface.
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Many materials or procedures are used to the surface of the
implant
Hydroxy apatite’s: Enhance or accelerate the initial bone
cells, adaptation or proliferation.
Oxide layer: Increase the roughness of the surface, also
could increase the roughness by machining or acid itching,
these will increase or promotes favorable cellular responses
and bone formation in close proximity to the surface.
Titanium (CP), Oxidizes within nanoseconds when exposed
to air. Because of this passive oxide layer, the titanium
becomes resistant to corrosion. The oxide layer of CP
titanium reaches 10 nm of thickness, it consists mainly of
titanium dioxide (TiO2) implant:
The effects of the surrounding
soft tissues:

1. The mucous membrane in the

sulcus less in the implant in
1-2 mm

2. The bers that connect the

cementum in natural tooth is
vertical and horizontal while
in implant only parallel to the
implant.
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Wound healing of the bone around surface of implant in uenced
by many factors :

1. Healing of the bone to the implant.

2. Healing of the soft tissues to the implant.

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 The rate between these two factors to form bone requires the
followings:
1. As short distance between bone and implant, as much as
possible.

2. Viable bone at or near the surface of bone along the implant.

3. No movement of the implant within the bone during attachment.

When a micro movement at the interface exceeds 150 nm, the
movement will impaired differentiation of osteoblasts and
brous scar tissues will form. Therefore it is important to avoid
excessive forces, such as occlusal loading, during the early
healing period.

4. Surface of implant must be free from contamination by organic

or inorganic materials.
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Necrosis of line of bone during drilling because of heat generation
and vessels trauma, so bone cells will die and only nonorganic part
will stay

Woven bone is quickly formed in the gap between the implant and
the bone, it grows fast, up to100nm per day, characterized by a
random orientation of its collagen brils, high cellularity, and
limited degree of mineralization, the biomechanical capacity of the
woven bone is poor. Thus any occlusal load should be well
controlled or avoided in the early face of healing.

After several months, woven bone is progressively replaced by

lamellar bone with organized, parallel layers of collagen brils and
dense.
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Biomechanical consideration: The
load-bearing capacity of the
integrated implant has to be greater
than the anticipated load during
function.

This capacity in uenced by many

factors:

1. The number and size of the

implants.

2. The arrangement and angulation

of the implants.

3. the volume and quality of the bone

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Thick cortical bone and dense trabecular
bone surrounding a long, wide diameter
implant that is positioned to be in a line
with the functional load, would offer the
greatest load bearing capacity and the
best prognosis for long term success.
Occlusal load applied at angle
more than 20 degrees or more can
result in load magni cation and
initiate bone loss and implant
failure.

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The number of implants of a space if three teeth where
lost , needs three implants with three crowns, if two
implants with cantilever, it will decreases the load bearing
capacity.
Connection of xed prostheses between implant and
natural tooth, will creates excessive cantilever loaded
situation and break down the Osteointegration.

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Non passive, ill- tting frameworks on the implant,
compressive forces are placed on the implant-bone
interface when the screw is tightened in attempt to seal
this work.

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Medical history:
1. Emergency or acute medical status: it is not a contraindication,
when the acute state pass anew evaluation for implant could be done.
2. Uncontrolled metabolic diseases: when the medical state goes to
controlled, the clinician will study the condition a gain.
3. Relative contraindications are concerned with medical conditions
that affect bone metabolism or patient ability to heal such as
diabetes, osteoporosis, immune compromise( e.g., HIV or AIDS),
medications (e.g., bisphosphonates), and medical treatment such as
chemotherapy and Radiotherapy) of the head & neck.
4. Some psychological or mental conditions depend on the severity.
Patient with psychiatric syndromes (e.g., schizophrenia, paranoia).
5. Patient with unrealistic expectation or uncooperative.
6. Certain habits such as smoking which has been documented as a
signi cant risk factor resulting in decreased long-term stability and
retention of the implant.
7. Patient with parafunctional habits ( bruxing and clinching)
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Dental history:
Past dental history of dental treatment problems.
Recurrent abscess.
A history of dissatisfaction to previous dental work, and
why?
Has the patient a lot of large llings.
oral hygiene.
patient attitude and motivation toward implants.
Did the patient understand the proposed treatment?
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 Intraoral examination:
It is performed to assess the current health and condition
of the oral hard and soft tissues. No pathological
conditions are present. Level of oral hygiene, periodontal
status, occlusion, jaw relationship, TMJ condition, and
any limitation in mouth opening.
Examination of the recipient area for implant, soft tissue
and space ( mesiodistal space) and (buccoligual space).
Any tilted adjacent tooth in the area of implant , measuring
the space by any instrument to see enough space
mesiodistally. Using diagnostic models and imaging
techniques to determine the space if it is available and
whether adequate bone volume exists to replace missing
teeth with implant.
We must leave 1-1.5 mm of bone around the implant and
1-2 mm in posterior lower bone for safety because of
inferior mandibular canal.
The minimum space must be available for implant with
diameter 4 mm is 6-7mm. The spaces available for implant
depend on the size of the implant.
Restorative (stack)
involve the abutment,
abutment screw to secure
the abutment to the crown
if it is not cemented. The
minimum amount of
interocclusal space
required for the
restorative (stack) on an
external hex-type implant
is 7mm.
Diagnostic elements:
Mounted study models as well as intraoral and extra oral
photographs are used for records and planning elements
that can be evaluated from mounted model include: 1-
Occlusal relationship. 2- Arch relationship 3- Inter-arch
space 4- Arch form, anatomy, and symmetry 5-
Preexisting occlusal scheme 6- curve of Wilson and curve
of spee 7- number and position of natural existing teeth 8-
Wear facets 9- -Tooth morphology 10-the relationship
between edentulous ridge and adjacent teeth 11-
measurement for planning future implant location 12-
Visualizing force factors
Intraoral photographs: they allow visual evaluation of the
soft tissues in many aspects: quantity, quality, location,
texture, color. And symmetry.
Extraoral photographs: they assist in:
1. Facial symmetry
2. Facial form
3. Facial features, facial hair, complexion, eye, color
4. Patient degree of expression
5. Smile line
6. Incisal edge or tooth display
7. Buccal corridor display
8. Potential esthetic smile
 Bone evaluation:
Clinical appearance can give some information about
de cit areas.
Palpation to feel for anatomic de cit and variations in the
jaw anatomy such as concavities and undercuts.
Sometimes there is enough bone but the placement of
implant is too buccal or too lingual so need bone
augmentation procedure to facilitate the placement of the
implant in an acceptable prosthetic position.
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Soft tissue evaluation: keratinized gingival tissue gives
good sealing around the implant abutment because it is
thicker and denser than non keratinized mucosa. It has a
cuff of circular (parallel bers).

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Some areas with non keratinized mucosa may need soft
tissue augmentation by gingival or connective tissue
graft.
Radiographic Examination : periapical, occlusal
(intraoral) or extraoral like panoramic, cephalometric ,
CBCT. Areas of study radiographically include:
1-Location of vital structures:
• Mandibular canal
• Anterior loop of mandibular canal
• Anterior extension of the mandibular canal
• Mental foramen
• Maxillary sinus( oor, septations, and anterior wall)
• Nasal cavity
• Incisive foramen
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2. Bone height
3. Root proximity and angulation of existing teet
4. Evaluation of the cortical bone
5. Bone density and trabiculation
6. Any pathology
7. Any anatomical variation like incomplete socket healing of an
extracted tooth.
8. Cross sectional topography and angulation by CBCT
9. Sinus health by CBCT
10.Skeletal relationship by lateral images cephalometric
We must notice the magni cation of the x-ray by putting metal
sphere near the plane of occlusion when taking the radiograph.
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Critical measurement speci c to implant placement
include:
1. Incisive canal should be avoided
2. 1.5 mm from the roots of adjacent teeth
3. At least 1 mm inferior to the oor of maxillary sinus
4. 5mm anterior to the mental foramen
5. 2mm superior to the inferior mandibular canal
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OPG is preferable radiograph to start with for evaluation
for placing implants .It is recommended by the American
Academy of Oral and Maxillofacial Radiology.
Surgical treatment:
After the surgeon clinical and radiological studies, and the
decision about the number and position of the implants that
will be inserted and the decision about the prosthesis was
made, now the surgical treatment are decided with the
following notes :

The most area which is suitable for implant is the

mandibular anterior region in front of the mental foramen
about 5mm. it is save because no mental foramen, and no
inferior mandibular canal and the bony ridge is thick and
the type of the bone is suitable and the ridge is long.
 The dif cult area for implant is the anterior maxillary
area , because:
1. the presence of nasal cavity and the incisive canal.
2. The buccal cortical plate is thin , after tooth loss, the
resorption of the ridge follows a pattern of moving
apically and palatally.
3. The result is a thin narrow residual angulated ridge in
such a way that ideal positioning of implant is impossible
and the esthetic outcome may be compromised.
4. The presence of nasal cavity so the implant must be
positioned 1mm below the cavity
5. and the implant should not be positioned in the midline
because of the incisive canal.
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The bone quality in the posterior maxillary region is the
poorest of any area, limited by thin cortical bone at the ridge
crest and the least dense trabecular bone. These result in less
implant stability at the time of placement. For this reason ,
more time (6months or more ) required for Osteointegration
to occur.

The maxillary sinus as bone resorption in the edentulous area

occurs, the sinus increase pneumotization, a limited height of
bone is present and the implant should be positioned 1mm
inferior to the oor of the sinus. The need for sinus lift
become more.
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The mandibular canal limits the positioning of the implant
since the need for at least 2mm superior to the canal which
traverse the body of the mandible .

It is important to consider the buccolingual position of the

nerve.

If the nerve is positioned in buccally , long implant can be

used lingually.

The attachement of mylohyoid muscle helps maintain the

bony width along the superior aspect of the ridge , although
the mandibular undercut ligually make a depression limit the
direction of the implant.
Final treatment planning: after all the clinical and radiological
information in addition to surgical options and limitations to
produce nal result of the prosthetic treatment. The position
and angulation of the implant placement is critical to the
biomechanical stability and esthetic required for long-term
success. To facilitate ideal implant placement , surgical guides
are frequently used.
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Four objectives of using a surgical template for partially
edentulous patient are :

1. Delineating the embrasure

2. Locating the implant within the tooth contour

3. Aligning the implant with long axis of the completed

restoration

4. Identifying the level of cementoenamel junction or tooth

emerges from soft tissue.
This guide provides the surgeon ease of access to bone and
uninterrupted visual con rmation of frontal and sagittal
positions and angulation.

CBCT data are used to produce a three-dimensional

reconstruction, which offers the ability to view anatomic
structures in cross section.

A computer-generated splint can be constructed with guide

sleeves matched to implant drill sizes.

The ultimate result should allow the surgeon to place the implant
optimally in bone while maintaining the angulation that
provides the best foundation for the nal restoration.
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One-Stage versus Two-Stage Implant
Placement Surgery