Lecture on implant dentistry for dental students

1. Implant Dentistry
RAKESH CHANDRAN

2. What is a dental implant?
An artificial titanium fixture placed surgically into the jaw bone to substitute for a
missing tooth and its root(s).
What is dental implantology/ implant dentistry?
Dental implantology is the field of dentistry that is concerned with the replacement of
missing teeth and their supporting structures with artificial prostheses anchored to the
jawbone.

3. Parallel sided and tapered, threaded screw shaped (root form), endosseous implants are
most commonly used. The lecture will focus on only this type of implant
Types of dental implants

4. Sub-periosteal implant
Types of dental implants- not commonly used
Ramus-frame implant
Plate-form implant
Transosseous implant

5. • Great majority of modern root form dental implants are “threaded” in design although
the thread pitch or profile can vary significantly between manufacturers.
• Implant surfaces also show variations. Surface hydrophilicity enhances adherence of
biomolecules and promotes the initiation of the osseointegration process.
• Almost all modern implants today have a microporous (rough) surface rather than a
relatively smooth machined surface. Roughness increases the surface area available
for more “bone-implant contact”.
Implant Design

6. • There are more than 150 companies that produce implant components. The most
established and well-known implant companies are Straumann and Nobel Biocare.
• Some of the implants available in South Africa
• Straumann
• Nobel biocare
• Southern implants
• Megagen
• Dentsply implants
• MIS implants
• ADIN implants
Implant manufacturers

7. Tissue level
parallel sided
Tissue level
tapered
Bone level
tapered
Bone level
parallel sided
Tissue level vs bone level implants*
• Implants that are designed to placed with the smooth (polished) collar above the bone
and at the level of the soft tissue are known as “tissue level implants”
• Implants that are fully inserted within the alveolar bone are known as “bone-level
implants”.

8. Length of an implant
• The lengths of the implant may vary between manufacturers.

9. Diameter of an implant
• The diameter of the implant may vary between manufacturers.

10. Describing an implant
For example, the implant on the left can be described as a
Straumann (make), 12mm length, 4.1mm diameter, bone level
implant.
• An implant can be described based on the make, the length, the diameter and
whether it is bone level or tissue level implant.

11. Cement retained restoration
1. crown
2. internal screw
3. abutment
4. implant
Implant restorations can be screw-retained or cement retained
Implant restorations

13. Different types of implant designs and surface characteristics
Barfeie et al 2015. Implant surface characteristics and their effect on osseointegration. BDJ

14. Comparison of tooth and implant support structures*

15. Comparison of tooth and implant support structures*
Structure Tooth Implant
Connection Periodontal attachment Osseointegration
Junctional epithelium Hemidesmosomes and basal lamina Hemidesmosomes and basal lamina
Connective tissue Thirteen groups: perpendicular to tooth
surfaces
↓ Collagen ↑ Fibroblasts
Only two groups: parallel and circular fibers
No attachment to implant surface and bone
↑ Collagen ↓ Fibroblasts
Biological width 2.04 to 2.91mm 3.08mm
Vascularity Greater, supraperiosteal and
periodontal ligament
Less, periosteal
Probing depth 3mm in health 2,5 to 5.0mm (depending on soft tissue depth)
Bleeding on probing More reliable Less reliable

16. Clinical comparison of teeth and implants*
• The vascular supply of the periimplant gingival or alveolar mucosa may be limited, as
compared to periodontal gingiva, due to the lack of a periodontal ligament. This may
render the periimplant tissues to be more prone to infection.
• Implants cannot intrude or migrate to compensate for the presence of a premature
occlusal contact (as teeth can).
• The absence of a periodontal ligament around implants reduces tactile sensitivity and
reflex function.

17. • No treatment
• A denture
• A bridge
• Implant treatment
Options of treatment for tooth loss

18. • Restore dental aesthetics
• Restore lost dental function:
- Chewing
- Speech
• Space maintenance and occlusal stability
• Orthodontic anchorage
• Convenience and comfort
• Bone preservation and prevention of disuse atrophy after tooth loss
What are the indications for dental implant treatment?*

19. ABSOLUTE CONTRAINDICATIONS
Implants cannot be placed in these situations:
Heart:
• Heart diseases affecting the valves (valvulopathy)
• Recent infarcts
• Severe cardiac insufficiency, cardiomyopathy
Miscellaneous:
• Active cancer, certain bone diseases (osteomalacia, Paget’s disease, brittle bones
syndrome, etc.),
• Certain immunological diseases, immunosuppressant treatments, clinical AIDS,
awaiting an organ transplant,
• Certain mental diseases,
• Strongly irradiated jaw bones (radiotherapy treatment)
Age:
• Children: not before the jaw bones have stopped growing (in general 17-18 years).
Contraindications for implant treatment*

20. Host (patient) risk factors can be local and systemic:
• Systemic disease (eg uncontrolled diabetes, immunosuppression or certain medication
like bisphosphonates)
• Local: radiotherapy, smoking, poor bone quality and density, periodontal disease,
occlusal trauma, parafunctional habits and bruxism, endodontic/ periapical lesions in
adjacent teeth, unfavourable smile line, unrealistic patient expectations and poor soft
tissue biotype etc.
Risk factors for implant placement*

21. Advantages
• implants do not involve preparation of the adjacent teeth
• implants preserve the residual bone
Disadvantages
• implant treatment can be expensive
• the patient requires surgery
• time consuming
• technically complex.
What are the advantages & disadvantages of implant over conventional treatment?*

22. • Good-quality clinical photography showing all standard views and site-specific views
• Two sets of study casts, one untouched and one used for planning
• A realistic tooth wax up or setup based on the above decision. At this point it will be
possible to see whether the definitive restoration is likely to be fixed or removable.
• Construction of a radiographic stent based on the tooth setup above with radiopaque
markers that will show up on a CT scan
• A sectional or full arch scan as appropriate using modern cone beam CT (CBCT)
• Analysis with suitable planning software to allow a realistic three-dimensional plan of
implant and restorative component positions.
• A decision as to whether sufficient bone exists and whether more advanced surgical
procedures will be required to provide bone volume
Special Investigations

23. • Ridge relationship
• Attached tissue
• Interarch clearance
• Inferior alveolar nerve
• Maxillary sinus
• Floor of the nose
Anatomic Considerations

24. • Surgical- placement of the implant
• Prosthetic- restoration of the implant
Procedure

25. Timing of implant placement*
Type 1 Immediate
the implant is placed immediately following the extraction of
a tooth
Type 2
Early
(4-6 weeks)
the implant is placed in a site where the soft tissues have
healed and mucosa is covering the socket entrance
Type 3
Early
(3-4 months)
the implant is placed in an extraction site at which substantial
amounts of new bone have formed in the socket
Type 4
Late
(>4 months)
the implant is placed in a fully healed ridge
Hammerle et al., 2004. Consensus Statements and Recommended Clinical Procedures Regarding the Placement of
Implants in Extraction Sockets. Int J Oral Maxillof Implants.

26. Bone grafts
A bone graft in implant dentistry is a surgical procedure for augmenting a deficient
alveolar ridge.
Sinus floor elevation
Maxillary sinus floor augmentation (also termed sinus lift, sinus graft, sinus
augmentation) is a surgical procedure which aims to increase the amount of bone in
the posterior maxilla (upper jaw bone), in the area of the premolar and molar teeth,
by lifting the lower Schneiderian membrane (sinus membrane) and placing a bone
graft.
Complementary procedures

28. One-stage surgery with the implant designed so that the coronal
portion of the implant extends through the gingiva.
One stage vs two stage procedure*
In the two-stage surgery, top of the implant is completely
submerged under gingiva.

29. • In the one-stage approach, the implant or the abutment emerges through the
mucoperiosteum/gingival tissue at the time of implant placement, whereas in the two-
stage approach, the top of the implant and cover screw are completely covered with
the flap closure.
• In two-stage implant surgery, the implant must be surgically exposed following a
healing period.
• The two-stage, submerged approach is advantageous for situations that require
simultaneous bone augmentation procedures at the time of implant placement
because membranes can be submerged, which will minimize postoperative exposure.
One stage vs two stage procedure*

30. Load
Any external mechanical force applied to a prosthesis, dental implant, abutment,
tooth, skeletal organ, or tissue.
Loading
Application of a force directly or indirectly onto a dental implant, tooth, or prosthesis.
Immediate occlusal loading
A clinical protocol for the placement and applying force on dental implants, with a
fixed or removable restoration, at the same clinical visit.
Early loading
Refers to the time of applying occlusal forces to a dental implant after its initial
placement. A prosthesis is attached to the implant(s), earlier than a more
conventional healing period.
Delayed loading
Refers to the time of applying occlusal forces to a dental implant after its initial
placement. A prosthesis is attached or secured after a conventional healing period.
Loading of an implant

31. Surgical Complications
• Hemorrhage and Hematoma
• Neurosensory Disturbances
• Implant Malposition
Biologic Complications
• Inflammation and Proliferation
• Dehiscence and Recession
• Periimplantitis and Bone Loss
• Implant Loss or Failure
Prosthetic or Mechanical Complications
• Screw Loosening and Fracture
• Implant Fracture
• Fracture of Restorative Materials
Complications

32. • Infection
• Bleeding
• Pain
• Swelling and bruising
• Suture granuloma
• Wound dehiscence and break down
• Membrane exposures
• Altered sensation or numbness to teeth, gum, lip etc.
• Devitalisation of adjacent teeth
Post-operative complications to look for:

33. • This can occur as a result of implant placement in close proximity of the inferior
alveolar nerve and particularly in case of poor surgical planning and/or technique. Any
report of paraesthesia or altered sensation occurring to the teeth, lip or the gum
should be investigated urgently and the signs and symptoms should be recorded. Early
referral to an oral surgeon would be an advantage.
• Signs and symptoms of nerve injury:
• Pain
• Numbness or tingly sensation
Damage to Inferior Alveolar Nerve

34. • Peri-implant disease refers to the pathological
inflammatory changes that take place in the tissues
surrounding a load bearing implant.
• Peri-implant disease presents in two forms: peri-implant
mucositis and peri-implantitis.
• Peri-implant mucositis is a disease in which the presence
of inflammation is confined to the soft tissues surrounding
a dental implant with no signs of loss of supporting bone
following initial bone remodeling during healing.
• Peri-implantitis is defined as an inflammatory process
which affects the tissues around an osseointegrated
implant in function, resulting in the loss of supporting
bone, which is often associated with bleeding,
suppuration, increased probing depth, mobility and
radiographical bone loss.
Peri-implant mucositis and peri-implantitis*
Peri-implant mucositis
Peri-implantitis

35. • Success means that an implant is present at the time of review and fulfils certain pre-
established criteria such as no pain, radiolucency, no bone loss, no peri-implant
pocketing etc.
• Survival means that, at the time of examination, the implant is simply present in situ
but the condition of the implant is not taken into consideration. In other words,
survival rates do not take in to account whether or not there are any problems with
the implant such as crestal bone loss or deep pocketing. Survival rates of dental
implants have been reported to be in excess of 90% after 15 years.
Success and survival of dental implants*

36. Structured courses offered in South Africa
• Postgraduate Certificate Course/ Diploma in Oral Implantology offered by the
University of Pretoria.
• Implant & Aesthetic Academy, Cape Town
• Diploma in Oral Implantology, University of Western Cape
Online education
• International Team for Implantology (www.iti.org)
• Foundation for oral rehabilitation (www.for.org)
• Dental Campus (www.dental-campus.com)
• Dental XP (www.dentalxp.com)
Furthering your education in implant dentistry

37. Thank you for your attention