Stat of the art dental implantology

4. Titanium and its alloys are well
known with excellent physical and
biological properties.

5. Biocompatibility of titanium is due to the native oxide film
(TiO2) that is created spontaneously on its surface upon air
exposure and appears to be responsible for its chemical stability,
chemical inertness and corrosion resistance.

6. There are four grades of cp-Ti depending on their content to
oxygen and iron.
Recently Grade 5, became commonly used for biomedical
applications (i.e., orthopedic and dental implants), because of its
enhanced mechanical strength.

9. An implant is not a tooth

10. dental implants are made from titanium. This material
selection is based on the well-established properties of
biocompatibility and corrosion resistance of those materials
that are attributed to the native surface oxide (TiO2), 2–
10 nm thick layer.
A dental implant is an alloplastic biomaterial that is
surgically inserted into the jaw bone to solve functional
and/or esthetic problems.
Dental implant

11. Osseointegration implies an anchorage mechanism,
whereby artificial components can be reliably and
predictably :
(1)Incorporated into living bone, and that this anchorage can
(2)Persist under all normal loading conditions .
The success of dental implants is largely attributed
to what is known as “osseointegration” a term
originally defined by Branemark in 1952.
Dental implant

12. Osseointegration begins with the absorption of ions,
proteins, polysaccharides, and proteoglycans by the Ti-
oxide layer .Afterwards, macrophages, neutrophils, and
osteoprogenitor cells migrate on the bone-implant
interface and lead to bone apposition in close contact with
the implant surface .
The osseointegration procedure takes a time
period of at least 3–5 months to be adequate a fact
that often complicates immediate loading of
dental implants.
Osseointegration

13. Osseointegration
(1)Implant's surface characteristics.
(2)Primary stability.
Parameters that contribute to a successful process of osseointegration:

14. Implant Surface Characteristics
A great variety of surface treatments exist today, in
order to achieve a desired degree of surface
roughness.
The different surface modifications can be divided
into many types:
(1)machined.
(2)plasma spray.
(3) Acid etching.
(4)Laser surface treatment, LST), acid etching,
(5)Grit blasting followed by acid etching.
(6)Anodizing.
(7)Biomimetic coating.

15. Xive [Germany]
Grit blasting +acid
etching.
Double acid-etched
+Calcium phosphate
surface.
BIOMET USA
BioHorizons USA
Laser Ablation
Nobel Biocare [Switzerland]
Anodic
Oxidation
Implant Surface Characteristics

16. *Needed for the biological process of
osseointegration to occur.
Implant movements, without primary stability,
even at the micrometer range, may negatively
influence osseointegration and bone remodeling
by forming fibrous tissues, thereby causing bone
resorption at the bone-to-implant interface .
(2)Primary stability.
[B]Bone quality
[A]Implant design
Factors affecting primary stability:

17. D1
D2
D3
D4
Bone Quality

18. ANT-
MAX
POST-
MAX
ANT-
MAND
POST-
MAND
D1 - - 6% 3%
D2 25% 10% 66% 50%
D3 65% 50% 25% 46%
D4 10% 40% 3% 1%
Usual anatomical location of bone density types-% of occurrence
Stress =
Force
Area
Bone density Implant S. area
Bone Quality

19. Primary stability estimation.

20. Primary stability estimation.
30-35N

21. Preferred insertion torque as a determinant of
implant primary stability, and torque values of
32, 35, or 40 Ncm and higher have been chosen
as thresholds for best primary stability.
Primary stability estimation.

22. Secondary stability

23. Secondary stability
Primary stability depends on mechanical engagement of an implant
with the fresh bone socket, but this stability declines with time
during the early stages of healing, as remodeling of the surrounding
bone takes place .
secondary stability is mainly influenced by implant characteristics and
surgical technique
While secondary stability is the progressive increase in stability
related to biologic events at the bone-implant interface such as new
bone formation and remodeling which increases with time.

24. One of the surgical techniques suggested to enhance the
primary stability of implant in bone of low density is the
undersized drilling technique, which has been introduced
to locally optimize the bone density by using a final drill
diameter considerably smaller compared with the implant
diameter . In this way, an osteocompressive fit between the
implant surface and bone bed is achieved.
Secondary stability

25. Repair and bone ingrowth, maturation, and
remodeling are cell-mediated processes.
Mechanical pressureSuitable conditions
Osteoblastic activity Osteoclastic activity
Secondary stability

26. Secondary stability
Micromotions above 50–100 micrometers may negatively
influence osseointegration and bone remodelling by
forming fibrous tissues and inducing bone resorption at the
bone-to-implant interface .
Therefore, a high initial (mechanical) stability is not the
only essential parameter for a successful osseointegration
of dental implants.

27. Periotest
Secondary stability estimation.

28. Timing of implant placement

29. [2]Presence of periapical pathology
[1]Absence of keratinized tissue
[3]Lack of complete soft tissue closure over the extraction socket
Timing of implant placement
[4] Bone grafting and membrane mostly required.
[5] Decrease in primary stability.
[6] Less chance for early loading.

30. Timing of implant placement
[1] Adequate keratinized overlying soft tissue coverage.
[2] Little effect of micro-organism.
[3] High osteogenic activity.
[4] Less cost. Bone grafting and membrane not required.

32. Bone density measurement:
Cone beam Bone density measurement:
The area of future
implantation x-rayed with
CBCT for determination of
implant length, width,
bone density and
approximation to vital
structures.

33. The use of low-level lasers has also been suggested of accelerating
and improving the bone tissue healing process.
Laser has bio-stimulatory effects on wound healing, collagen
synthesis, and fibroblast proliferation. In addition, it has been
demonstrated that bone shows increased osteoblastic proliferation,
collagen deposition, and bone formation .
low-level lasers

34. Improve bone quality [use of osteotome].

35. Improve bone quality [by control of drilling size].
Selected Implant size
is larger than drill size
by 0.2-0.5.

36. Improve bone quality [by grafting].
Alloplastic material [osteoconductive]
Natural Bone [osteogenic]
Combination[Composite grafting].
Bone induction material [osteoinductive].

38. Osteo induction

39. (1)it is of autologous origin; contains growth factors that play an
active role in bone formation[by induction].
(2)PRP application to bone graft materials leads to earlier bone
regeneration and soft tissue healing.
Platelet Rich Plasma PRPOsteo induction
Improve bone quality [by grafting].

40. Bone collectorTrephine preparation Remote site graft
Improve bone quality [by grafting].
Natural Bone
tuberosity
symphysis
Posterior mandible
Iliac bone
Osteogenic

41. Alloplastic material
Osteocoduction
Act as scaffold for new bone formation.
Act as source of minerals for the newly formed bone.
βTri-Calcium phosphate.
Hydroxyapatite.

42. Alloplastic material

43. βTri-Calcium phosphate.
Hydroxyapatite.
Combination.

46. Improvement
of
ridge width
Improvement
Of
ridge length

47. Improvement of ridge width
Grafting with alloplastic material
Grafting with composite graft.
-Grafting with alloplastic material plus spongy bone
-Grafting with cortical bone

48. Grafting with alloplastic material
1-Easy to perform.
2-Could be applied for any implant size.
3-Saving time.
4-No second surgery required.
5-Economic
Advantages:
Disadvantages:
1-Graft affected by external pressure
[displacement].
2-Poor quality of bone formation.
-Not suitable for early loading.
- Short implant life.

49. Use of membranes
Grafting with alloplastic material

50. Use of membranes
Grafting with alloplastic material
GBR
1-Improves bone quality by guided regeneration.
2-Maintain contour of grafted material.

51. Polylactic
acid
1-Secondary operation required.
2-Displacement of the graft still problematic.
1-Displacement of the graft still problematic.
2-Inflammatory reaction decrease bone bulk.
Cytoplast
Gore-tex

52. Use of membranes
Titanium mesh fixed with tacks
-Displacement of the graft material prohibited.
-Good support with improvement of implant life.
-No secondary operation required.
-Resorbable tacks is now available.

53. Grafting with composite graft.
1-Natural bone is the best for
restoring cortical plate.
2-No need for second surgery by
use of resorbable screws .
Advantages:
Disadvantages:
1-Donor site morbidity.
2-In most of cases immediate implantation is
not possible.

54. Natural cortical bone stores

55. Split bone technique

56. Use of Piezotome
By use of chisel and mallet Use of rotary instruments
Split bone technique
Advantages
1-No need for guided membranes.
2-Considerable width obtained.
3- Require less amount of grafting material.
4-Buccal and lingual/palatal bone are natural.
5-Considerable primary and secondary stability.
6-Could be achieved by flapless technique.
7-Could be combined with bone condensation.
8-Ridge correction and implant insertion
performed in one step.
Disadvantages
1-Bone should be D2 or D3.
2-Fracture of buccal bone is frequent .
3-Considerable skill is required.
4-The ridge should be with
considerable length.

57. Improve ridge length
Required when both labial[buccal]and
lingual[palatal] bones are vertically resorbed.

58. Improve ridge length
Bone ring technique

59. Improve ridge length
Interpositional bone
graft in the posterior
mandibular region.
Improvement of
ridge length with
cortical bone in the
critical area.

60. Improve ridge length
Bilateral cortical bone
Improvement of both ridge
width and length.

61. Improve ridge length
Distraction osteogenesis

62. Improve ridge length
On lay graft
Iliac crestTibia&FibulaRib graft Radius

63. Improve ridge length
Sinus lift procedure
Closed procedures
Open procedure
Performed through Alveolar ridge.
Performed through lateral sinus wall.
Lifting of maxillary sinus
membrane followed by bone
grafting to increase the
future implant length.

64. Improve ridge length
Sinus lift procedure
Open procedure
Open window
Trap door
Performed through lateral sinus wall.
Lateral sinus wall is
completely removed.
Lateral sinus wall is
moved upward below
the sinus membrane.

65. Improve ridge length
Sinus lift procedure
Closed procedures
By using osteotome By using balloon .

66. Improve ridge length Sinus lift procedure Closed procedures
By using osteotome

67. Improve ridge length Sinus lift procedure Closed procedures
By using osteotome

68. Improve ridge length Sinus lift procedure Closed procedures
By using osteotome

69. Improve ridge length Sinus lift procedure Closed procedures
.
By using balloon

70. Sinus lift
Vertical
ridge augmentation

71. Sinus lift
Sinus lift
Vertical ridge augmentation
Bone graft

72. Ridge augmentation is
recommended in cases
finished with improper
crown root ratio.
Sinus lift is
recommended in cases
with sinus
pneumatization.

74. Complications
And
problems solving

75. Implant failure.
Gingival recession with exposure of implant.

76. Biological failures
Mechanical failures
Smoking
Post-op infection surgical trauma during preparation
Local infection or inflammation.
Radiotherapy.
Diabetes.
Periodontal disease.
Improper selection of implant.
Malfunction & Bad habits.
Improper load distribution.
Mixed abutments [natural teeth & implant].
 implant micro-movements.
Implant failure. Biological failures &Mechanical failures

77. Early failures
Occurs after implantation and before loading.The
process of osseo-integration does not succeed due to
various reasons.
Implant failure.
late failures
progressive loss of bone support, mostly during the
first year after loading.
Early failures & late failures

78. Early failures
Occurs after implantation and before loading.
surgical trauma during preparation.
Post-op infection.
implant micro-movements.
The process of osseointegration does not
succeed due to various reasons, such as :
Implant failure.

79. late failures
progressive loss of bone support, mostly during the
first year after loading as a result of:.
Implant failure.
Improper selection of implant.
peri-implantitis
Smoking.
Local infection or inflammation.
Radiotherapy.
Diabetes.
Periodontal disease.
Malfunction & Bad habits.
Improper load distribution.
Mixed abutments [natural teeth & implant].

80. Early failures
Implant failure.
surgical trauma during preparation.
1-Use of dull drills.
2-Over compression of bone.
3-Insufficient cooling.
4-Using of high speed during preparation.
5-Multidirection drilling.
6-Undersized cortical bone drilling.
7-Traumatic extraction of roots[immediate insertion].
8-changing of implant surface characteristics.

81. Early failures
Implant failure.
Post-op infection.
1-Neglect antibiotic prescription.
2-Previous infected implant site.[immediate implantation].
3-Neglected oral hygiene.
4-Smooking.
5-Immune compromised patients.
6-Irradiated patients.
7-Excessive trauma during surgical procedure.
8-Absence of aseptic environment.
9-Unprotected implants/graft/membrane.
10-Blood born infection.

82. Early failures
Implant failure.
implant micro-movements.
1-Early loading without proper
primary stability.
2-Decrease in secondary stability.
3-Improper grafting material
[early resorption].
4-Overpressure from temporary
restoration.
5-Peri-implantitis.

83. late failures
progressive loss of bone support, mostly during the
first year after loading as a result of:
Improper selection of implant.
Improper load distribution.
peri-implantitis
Smoking.
Local infection or inflammation.
Radiotherapy.
Diabetes.
Periodontal disease.
Malfunction & Bad habits.
Mixed abutments [natural teeth & implant].
Implant failure.

84. late failures
Implant failure.
Improper selection of implant.
Implant Sizing
1) Length
Implant length and diameter have an influence on the stress
distribution at the bone-implant interface, as well as on success rates.
2) Diameter
it was determined that the implant diameter was much more
important in stress dissipation than implant length.
3. Biomechanical factors
Masticatory forces acting on dental implants can also result in
undesirable stress within the surrounding jawbone, and this can
cause bone resorption and eventual failure of the implant

85. Avoid increase implant diameter more than natural tooth diameter.
Avoid decrease implant length more than clinical crown.[crown:root ratio].
Natural Crown-Root ratio
1:2 or more.
Least Crown-Root ratio
1:1

86. Late failures
Implant failure.
Improper load distribution.
1-Improper implant angulations.
2-Improper use of angulated abutment.
2-Insufficient implant number.
3-Very long clinical crown.
implant may tolerate up to 150 N of lateral force before
a micro-movement is induced and osseo-integration is
lost.

87. 1-Loosening of abutment screw.
2-Fracture of abutment screw.
3-Fracture of implant.
4-Progressive bone loss.
5-Peri-implantitis.
Late failures
Implant failure.
Improper selection of implant.
Improper load distribution.

88. late failures
Implant failure.
peri-implantitis :
A condition of inflammation may be accompanied
with bacterial infection, if neglected, resulted in
progressive bone resorption and early loss of the
implant.
There are a lot of causes for peri-implantitis the most common are:
Smoking.
Local infection or inflammation.
Radiotherapy.
Diabetes.
Periodontal disease.
Malfunction & Bad habits.

89. Mixed abutments [natural teeth & implant].
late failures
Implant failure.
Micro-movements of natural teeth due
to the effect of periodontal ligament
lead to extra lateral stresses on the
implant resulted in progressive bone
resorption.

90. The mean of marginal bone loss occurring
around implants after the first year of insertion
found is 0.93 mm, with a range of 0.4 to 1.6 mm
The ongoing annual bone loss should be less
than 0.2 mm.
late failures
Implant failure.