PERIODONTICS

2. Dental implants
Department of periodontics
Dr.Mahesh Raj V.V.

3. Definition
 Dental implant is a biologic or alloplastic
biomaterial, which is surgically inserted into
the soft or hard tissues of the mouth for
functions or cosmetic reasons
 An alloplastic and biocompatible material
placed in to or on to the jawbone to support a
fixed prosthesis or to stabilize removable
prosthesis

4. Fudamental science
 Osseointegration – (Branemark 1986)-
direct structural and functional connection
between ordered living bone and the surface
of a load carrying implant
 SG Steinemann – defined it as direct contact
between bone and implant surface

5. Osseointegration (phases)
 Blood clot formation at implant-bone interface
 Infiltration of neutrophils and macrophages(3-5days)
 Local hypoxia
 Release of cytokines
 Neovascularisation
 Cellular differentiation
 Matrix synthesis
 Osteogenesis
 Woven bone formation
 Lamellar bone formation

6. Successful osseointegration
 Absence of mobility clinically
 Asymptomatic
 Stable crestal bone level
 Increased mineralization
 Healthy soft tissue
 Absence of Peri-implant radiolucency
 RoughenedTi Implant surface is better than
conventionally machinedTi surface

7. Contact and Distant osteogenesis
Contact osteogenesis
New bone synthesis begins
at the implant surface
Distant osteogenesis
New bone synthesis begins
at the osteotomy wall

8. OsseointegrationVs Osseocoalescence
 Osseointegration- refers to physical integration or
mechanical fixation of an implant in the bone
 Osseocoalescence/ Biointegration- refers to the
chemical integration of bone to the surface
enhanced active materials (HA,BG) on the implant
surface
 Osseointegration- provides good resistance to shear
forces but poor resistance to tension
 Osseocoalescence- provides good resistance to
both shear and tensile forces

9.  Primary stability- mechanical stability achieved during
implant insertion
 Secondary stability- stability achieved by means of
Osseointegration (4-6months)
 Soft tissue integration- Biological processes that occur
during the formation and maturation of the structural
relationship between the soft tissue and the transmucosal
implant superstructure

10. Anatomic features
ImplantVs Natural tooth
Features Periodontal tissue Peri- implant tissue
Periodontal ligament Present Not present
Sulcular epithelium Present Present
Junctional epithelium Present Present
Basal lamina Present Present
Hemidesmosomes Present Present
Glycoprotien adhesion Present Present
CT attachment Present Absent
Soft tissue circulation Three sources
(PL, Bone, periosteum)
Two sources
(Basal bone, periosteum)
Surrounding CT Vascular and cellular Hypovascular and

11. classification
 A – Endosteal/Endosseous
 B - Subperiosteal
 C –Transosteal/Transosseous
 Basal osseointegrated implants (BOI)

12. Endosteal implants
 A device placed in to
the alveolar and or
basal bone of the
mandible or maxilla,
transects only one
cortical bone

13. Endosteal implants(forms)
 1- Rootform/
cylindrical
 2- Bladeform ( a thin
elongated , flat device
designed to be secure
in narrow or even knife
edged alveolar bone)
Eg: Ramus frame
Implant

14. Subperiosteal Implant
 It employs an implant substructure &
superstructure, which rests on the
alveolar bone beneath the gingiva
 Placed under the periosteum and
fixed over the jaw bone (severely
resorbed mandible)

15. Tranosteal/Transosseous Implants
 It combines with both
subperiosteal and
endosteal components
which penetrates both
cortical plates and
passes trough full
thickness of alveolar
bone
 (restricted to anterior
mandible)

17. Basal osseointegrated implants
 Indicated for cases with limited bone volume,
bone height above mandibular canal, sinus
pneumatization
 Needs lateral approach (lateral bone cutter to
prepare lateral slot)
 Engages basal bone or disc bicortically

18. Implant Macrodesign
(3 types)
 1 – cylinder root form
 2 – screw root form
 3 - combination

19. Cylinder root forms
 Offers the advantage
of ease of placement in
difficult access
location( type IV bone)
 Are either smooth
sided or bullet shaped ,
requires a bioactive
surface for better
integration

20. Screw root forms
 Common
 Square
 V shaped
 Buttress threads
 Variations
 Straight
 Tapered
 Conical
 Ovoid
 Expanding body

21. Combination
 Posses macroscopic
features of both
cylinder and screw root
forms

22. Classification (Root form implants)
 A- Based on surface design
- Non threaded implants
Offers the advantage of more surface area and more bone implant –
surface contact
eg: endopore
– Threaded implants
B – Based on body design
- Parallel body
- Tapered

23.  C- Based on implant connection
 External connection (external hex)
 Implant connection emerges above the implant platform and act as the
male part where all implant components gets engaged
 Internal connection (internal hex)
 Implant connection remain inside the implant body and act as female
part

24.  D – based on
connection design
 Triangular design – 3
faces
 Hexagonal design – six
faces
 Octagonal design –
eight faces

25. Smooth surface /non-hex
(cold- weld )design
 Doesn’t have any faces,
but a smooth surface tube
in tube connection
 Abutment gets cold
welded in to the implant
connection
 Prevents microbial growth

26.  Morse taper connection
 Combination of both hexed and non hexed
 (coldwelded, Tube in Tube) connection
 Has a hex in the deepest half of internal connection as anti
rotational features
 Its smooth non hexed surface in crestal half makes a tight seal to
prevent bacterial growth

27.  E- Based on materials used
 Titanium and its alloy implants
 Zirconium implants
 F- Based on thread design
 Square / u shaped- Non – cutting thread
 V shaped – cutting/self tapping thread

28.  G- Based on crestal polish collar
 Subgingival (two stage implants)
 Trans gingival (one stage ) implant
 H- Based on implant pieces
 Two - piece implant
 One – piece implant

29. Classification of implants

30. Implant Abutment Interface
 Implant is connected to the abutment by
coupling which is external about 2mm superior
and internally about 5 mm inferior to the
coronal surface of implant
 External connection is either a standard
hexagonal or octagonal with 0.7mm platform

31. Continuation.............
 Internal connection
(slipfit/ frictionalfit)
 Slip fit – passive fit of
abutment part of
implant like octagonal,
hexagonal, cone screw
with a non rotational
feature
 Preferred- Deep
internal hexagon

33. Implant Biomaterials
A- Metals
 Stainless steel
 Cobalt-chromium-molybdenum based
 Titanium and its alloys (Ti-Al-Va)
B- Ceramics
 Hydroxyapatite
 Bioglass
 Aluminium oxide
 Polymers and composites
 Others, gold, carbon etc

34. Micro design- surface coating
 Anodization – prevent corrosion of pure titanium by oxidization (TiO2)
 Hydroxyapatite coating-
 Better osseointegration
 Gap healing can be enhanced by HA coating
 Less metal corossion
 High success rate in D4 bone
 Plasma nitriding or spraying- done by spraying molten metal inTi base - (Increases
tribiological properties(Biocompatibility, Bio adhesion, Biofunctionality)
 Polyethylene grafted polycationic polymers – gets bond to negatively changed TiO2
which helps surface proteins to bond with surface modified titanium
 Alkaline treatment- create a porous, hydrated and reactive titanium oxide surface

35.  Laser treatment- melt surface layer locally to
embed a new phase in a substrate
(CO2, Nd-YAG laser)
 Sand blasted ( using Al2O3 ,TiO2 & CaPo4)and
Acid etched surface( using HCL,H2So4)- increase
surface roughness by producing macro/
micro texture , increases BIC-(bone implant
contact) percentage

36. Implant components
 A-Fixture or implant body
 B- Implant abutment or Transmucosal abutment
 Implant mount
 Cover screw
 Gingival former/healing abutment/permucosal extension
 Impression post/impression transfer abutment
 Implant analogue
 Abutment screw
 C- Actual prosthesis
(Screwed joints/ cemented joints)

37. Implant components
1- Implant fixture/Implant body
 Implant itself which gets osseointegrated with the bone
2- Implant mount
 Used to carry implantfrom its vial
3- cover screw
 Used to cover the implant connection during submerged healing
4- Gingival former/healing screw/ abutment/ permucosalextension
 Used to form a healthy , aesthetic emergence profile
5- Impression post
 Used to transfer the implant hex position and orientation from mouth to working cast
6- Implant analogue
 Has a different body with similarplatform and connection of implant
7- Transmucosal abutment
 Serves as an attachmentbetween implantand actual prosthesis

38. Implant components
IMPLANT FIXTURE IMPLANT MOUNT

39. COVER SCREW GINGIVAL FORMER

40.  Impression post  Implant analogue

41. Types of impression post
CLOSEDTRAY IMPRESSION POST OPENTRAY IMPRESSION POST

42. Open tray impression post
 It posses deep retention grooves along its
body and long connection screw
 A part of its long screw emerges out of the
impression tray and should be unscrewed
before removing the impression from
implant so that the post comes out
embedded in the impression
 The impression is then poured in die stone

43. Open tray impression

44. Closed tray impression post
 It posses shallow retention grooves along its body and short connection
screw
 The complete post remains under the impression and no part of it
emerges out of the tray
 After making impression this post is removed from implant , assembled
to analogue and inserted to the impression with the same orientation
 The impression is first poured with soft tissue replicating material
followed by dental stone

45. Closed tray impression technique

46. Abutment (classification)
 1 Abutment for ball
retained over dentures

47.  2 Abutment for cement
– retained fixed
prosthesis
 a- Straight abutment
 b- Angled abutment
( 5,15,25,30)
 c- Anatomical / Aesthetic
abutment
 d- Zirconium abutment
 e-Temporary abutment

48.  3-Plastic or castable
abutment

49.  4- abutment for
abutment level screw
retained fixed
prosthesis

50. 5-Engaging abutment
 Has triangular or octagonal hex
connection so can be fixed only to
implant at particular oriental position
Non engaging abutment
 Do not have any connection so can be
fixed at any orientation

51. 6-UCLA abutment-
castable abutment
7- Multi unit abutment
 (17 and 30 degree
angulations)
 Used in all on 4 and all
on 6 technique

52. Platform switching or common platform concept
 Are implant with similar platform so that any of the components could be fitted to any implant in a
particular system irrespective of diameter
 When smaller diameter abutment is used over the regular or wider implant , it forms an implant –
abutment junction narrower than diameter of implant , apical to and diameter of abutment occlusal to
this junction
 Such junction provided stress free space for formation of thick bone and soft tissue in crestal region
 Platform switching may reduce crestal bone resorption by about 70%

53. Inventories for basic implant procedures
 Dental implant surgical kit
 Implant motor (physiodispensor)
 Rotary reduction hand piece
 Basic oral surgery instruments

54. 1- Dental implant surgical kit
 Large round carbide bur
 Small round carbide bur
 Pilot drill
 Width- increasing/widening drills
 Parallel guide/depth guide
 Parallel and spacing guide
 Drill stoppers
 Bone tap or thread former
 Crestal bone drill/ counter sink drill
 Drill extender
 Implant depth probe
 Implant driver- rotary hand piece/ hand ratchet driven
 Ratchet – wrench/ torque ratchet
 Screw driver / hex driver

55. Implant surgical kit

56. Surgical drills

57. Drilling sequence for different diameter implants

58. Paralleling pins & depth guide
PARALLELING PINS DEPTH GUIDE

59. Drill stopper/ implant depth probe
DRILL STOPPER IMPLANT DEPTH PROBE

60. BONE TAP/ THREAD FORMER
(20-40 RPM)
CRESTAL BONE / COUNTER SINK DRILL (1500-2000 RPM)

61. Drill extender

62. Implant driver
HAND RATCHET DRIVEN HAND PIECE DRIVEN

63. Ratchet
RATCHETWRENCH TORQUE RATCHET

64. Screw driver/ Hex driver

65. Physiodispensor
 Torque control(0-50Ncm)
 Speed control
 Implant insertion- (20rpm)
 Hard bone drilling(2500rpm)
 20:1 speed reduction hand piece
 1:1 hand piece- (osteoplasty,bone
harvesting, sinus window preparation)

66. Rotary hand piece
 1:1 straight/ contra
angle
 20:1 speed reduction
Hand piece
New generation fibre
optic hand piece

67. Thank you