2. WHAT IS A DENTAL IMPLANT?
Dental implant is
an artificial titanium
fixture
which is placed
surgically into the
jaw bone to
substitute for a missing
tooth and its root(s).
3. History of Dental Implants
In 1952, Professor Per-Ingvar Branemark,
a Swedish surgeon, while conducting research
into the healing patterns of bone tissue, accidentally
discovered that when pure titanium comes into
direct contact with the living bone tissue, the two
literally grow together to form a permanent
biological adhesion. He named this phenomenon
"osseointegration".
4. First Implant Design by Branemark
All current implant
designs are
modifications of this
initial design
5. Surgical Procedure
STEP 1: INITIAL SURGERY
STEP 2: OSSEOINTEGRATION PERIOD
STEP 3: ABUTMENT CONNECTION
STEP 4: FINAL PROSTHETIC
RESTORATION
6. Fibro-osseous integration
• Fibroosseous integration
– “tissue to implant contact with dense collagenous
tissue between the implant and bone”
• Seen in earlier implant systems.
• Initially good success rates but extremely
poor long term success.
• Considered a “failure” by todays standards
9. Osseointegration
• Success Rates >90%
• Histologic definition
– “direct connection between living bone and load-
bearing endosseous implants at the light
microscopic level.”
• 4 factors that influence:
Biocompatible material
Implant adapted to prepared site
Atraumatic surgery
Undisturbed healing phase
41. Soft-tissue to implant interface
• Successful implants have an
– Unbroken, perimucosal seal between the soft
tissue and the implant abutment surface.
• Connect similarly to natural teeth-some
differences.
– Epithelium attaches to surface of titanium much
like a natural tooth through a basal lamina and
the formation of hemidesmosomes.
42. Soft-tissue to implant interface
• Connection differs at the connective tissue
level.
• Natural tooth Sharpies fibers extent from the
bundle bone of the lamina dura and insert into the
cementum of the tooth root surface
• Implant: No Cementum or Fiber insertion.
Hence the Epithelial surface attachment is
IMPORTANT
55. Patient Evaluation
• Medical history
– vascular disease
– immunodeficiency
– diabetes mellitus
– tobacco use
– bisphosphonate use
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56. History of Implant Site
• Factors regarding loss of tooth being replaced
– When?
– How?
– Why?
• Factors that may affect hard and soft tissues:
– Traumatic injuries
– Failed endodontic procedures
– Periodontal disease
• Clinical exam may identify ridge deficiencies
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57. Functional examination
Examination of smile:
Ackerman et al differentiated between two types of smile:
- posed smile (social smile, forced smile) …
voluntary, reproducible.
- spontaneous smile ( enjoyment smile) …
involuntary, induced by joy.
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58. Examination of smile
Ackerman et al used a “smile mesh” computer program to
analyze photographs of posed smiles using the Occlusal Plane
and the Dental Midline as reference planes.
He concluded that the posed smile is reproducible if
photographs were taken On The Same Day
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59. Smile related to natural dentition: (SMILE
LINE)
- posed smile … the
smile-line is at the
gingival margin.
- lower smile-line …
senile appearance.
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60. Smile Line
• One of the most influencing factors of any
prosthodontic restoration
• If no gingival shows then the soft tissue
quality, quantity and contours are less
important
• Patient counseling on treatment expectations
is critical
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61. SMILE LINE
FEMALE MALE
MORE GINGIVAL DISPLAY LESS GINGIVAL DISPLAY
MORE LOWER INCISOR SHOW
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62. SMILE ARC:
- Consonant the curvature of the
max. incisors is parallel to that of the
lower lip.
- nonconsonant the curvature of
the max. incisors is flat … senile
appearance.
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63. SMILE ARC:
NORMAL REVERSE
(CONSONANT)
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64. Transverse dimension of smile:
- broad smile … 1st molar may be shown
at the commissures.
- buccal corridors … improved by :
1- maxillary widening.
2- ,, advancement.
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67. Biocompatibility of Material
Desired Mechanical Surfaces
Properties
• Composition
• High yield strength
• Ion release
• Modulus close to that
of bone’s • Surface
• Built-in margin of modifications
safety: Changes in
environment around
implant
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68. Metallic Implant Surface
Problem:
Implant surface change with time due to oxidation,
precipitation…
Possible solutions:
• Oxide layers ( minimize ion release)
• Prosthetic component from noble alloys
• Phase stabilizers other than Al & V (eg. Ti-13Nb-
13Zr, Ti-15Mo-2.8Nb )
• Surface Modifications
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69. Types of Implants
Screw Implants
(Left to Right: TPS screw,
Ledermann screw,
Branemark screw, ITI
Bonefit screw)
Cylinder Implants
(Left to Right: IMZ, Integral,
Frialit-1 step-cylinder,
Frialit-2 step-cylinder)
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70. Procedure
First Surgical Phase (Implant Placement)
Under Local anesthetic the dentist places dental
implants into the jaw bone with a very precise
surgical procedure. The implant remains covered
by gum tissue while fusing to the jaw bone.
Second Surgical Phase (Implant Uncovery)
After approximately six months of healing. Under
local anesthetic, the implant root is exposed and a
healing post is placed over top of it so that the
gum tissue heals around the post.
Prosthetic Phase (Teeth)
Once the gums have healed, an implant crown is
fabricated and screwed down to the implant.
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71. What Is A Dental Implant?
Dental implants are used to:
Replace a missing tooth
Replace multiple missing teeth
Replace an edentulous arch
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73. Implant vs Conventional Bridges vs. Removable
Dentures
• There is a clear benefit to receiving dental implants
• Quality of life improves
• Diet and nutrition are positively impacted
• Positive impact on leisure activities
• Disadvantage of cutting down perfectly healthy teeth
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75. Doctor Friendly Procedures
• Transition from 2-stage to 1-stage procedures
• Immediate load implants
• Less invasive dental implant therapy
• Tilted implants, guided flapless surgery
• Advances in ceramic materials create a shift from
function to esthetics
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76. Concerns About Recommending
Dental Implants for the Elderly Fact or
Fiction…
Longer healing time
Inadequate osseointegration of implants
Loss of implants due to inadequate oral
hygiene
Patient’s desire and expectations for
dental implants may differ with age
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77. Patient’s Expectations
• Increased resistance to implant surgery -
“I’m too old”.
• Long-term edentulous patients may be
more tolerant to ill-fitting conventional
dentures.
• Recommendations for implant-assisted
restorations should occur early in
edentulism.
• Elderly patients may take a greater period
of time to adapt to a new prosthesis.
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78. Success Rate of Implant
Placement
• Success rate of implants in the healthy
elderly population is the same as that
of younger age groups.
• Degree of osseointegration with
healthy geriatric patients is comparable
to that of the younger population.
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79. Mandibular Overdentures
• Improve the stability and retention of the
denture.
• Can be placed over tooth roots or over
implants.
• Tooth roots provide sensory feedback but
can decay or lose support due to
periodontal disease or fracture.
• Both tooth roots or implants will help
retain the bone in the mandibular ridge.
ikassem@dr.com
80. Growing Need for Satisfactory
Tooth Replacement
• Tooth replacement with implant-supported or assisted
dentures provides greater patient satisfaction with
comfort and chewing.
• Stability and retention of denture is improved.
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81. Risk Factors for Dental
Implant Success in the Elderly
• Oral Hygiene
• Xerostomia
• Cardiovascular disease
• Diabetes
• Osteoporosis
• Cancer
Implant therapy should be considered as a medical model in
the geriatric population.
ikassem@dr.com
82. Lessened Manual Dexterity and
Visual Acuity May Affect
Oral Self Care Oral Hygiene
Success rate may be comparable to younger age
groups when…
• Appropriate modifications of oral health aids are made.
• When adequate instruction and recall intervals are
maintained.
• Less complicated designs of implant abutments are utilized.
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96. MAXILLARY IMPLANTS
• Lack of well defined cortex
• Poorer quality cancellous bone
• Lack of bucco/lingual width
• Reduced height of available bone
• Proximity of anatomical structures- nose
- antrum
- incisive canal
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109. COMPLICATIONS
Second stage
– Loose implant
– Excess bone coverage
– Exposed threads
– Coverscrew problems
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110. STAGE TWO SURGERY
• Wrong abutment length
• Faulty abutment seating
• Retained sutures
• Gingival hyperplasia
• Mobile tissue
• Destroyed cover screw hex
• Failure of integration
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111. FAULTY PLACEMENT
• Labial / buccal
• Lingual
• Too close
• Straight line in mandibular anteriors
• Angulation
• Divergence
• Correct by use of a surgical template
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115. PROSTHODONTIC
• Avoid premature loading
• Passive fit
• Good design
• Good oral hygiene
• Loss of integration
• Soft tissue problems
• Oral hygiene and maintenance
• Retrievable v cemented
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123. Diagnosis and Treatment Planning For Bone Augmentation
Radiographic Examination
• Panoramic radiograph
• 20 to 30% distortion/magnification of the
anatomic structures
• Buccal to lingual width will not be appreciated
• Alveolar bone height, adjacent teeth and
anatomic structure
131. Factors that impact on fit: atrophy
1. Atrophy
a. Decreasing bone
b. Increasing soft tissue
1
3
2
4
132. Factors that impact on fit: atrophy
1. Atrophy
a. Decreasing bone
b. Increasing soft tissue
133. Factors that impact on fit: atrophy
1. Atrophy
a. Decreasing bone
b. Increasing soft tissue
134. Diagnosis and Treatment Planning For Bone Augmentation
Clinical Examination
• Minimal obtain 1 to 2mm of attached
gingiva
• Cross section of the alveolar depicting
periodontal probe placement for “sounding
the bone”.
• To determine bone width
• Cutting the study model in the exact vertical
location
135. To Determine Bone Width
Harry Dym, Orrett E. Ogle: Atlas of Minor Oral Surgery. W.B. Saunders
company. 2001
141. FREEZE DRIED BONE
• Commercial preparation
• Multiple donors
• Screened for HIV, Hep B and C
• Sterilised by irradiation
• Risk of prion borne disease
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150. Anatomic Limitations
Buccal Plate 0.5mm
Lingual Plate 1.0 mm
Maxillary Sinus 1.0 mm
Nasal Cavity 1.0mm
Incisive canal Avoid
Interimplant distance 1-1.5mm
Inferior alveolar canal 2.0mm
Mental nerve 5mm from foramen
Inferior border 1 mm
Adjacent to natural tooth 0.5mm
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151. Types of Bone Grafts
• Autograft
– A graft taken from on anatomic location and placed in another
location in the same individual(e.g., iliac crest)
• Allograft
– A graft taken from a cadever treated wit certain sterilization and
antiantigenic procedures and placed into a living host
• Alloplast
– A chemically derived nonanimal material
• Xenograft
– A graft taken from a nonhuman host for implantation into a human
host
152. Biology of Bone Grafts
• Phase I
– Osteogenesis: Immediate proliferation of transplanted
osteocytes and subsequent formation of osteoid(immature
bone)
• Phase II
– Osteoinduction: inducement of mesenchymal cells to
produce bone(BMP)
– Osteoconduction: framework or scaffold for the formation
of new bone tissue
153. Autogenous Bone Graft
• “Gold standard”
– Standard by which other materials are judged
• May provide osteoconduction, osteoinduction
and osteogenesis
• Drawbacks
– Limited supply
– Donor site morbidity
154. Autogenous Bone Grafts
• Cancellous
• Cortical
• Free vascular transfers
• Bone marrow aspirate
155. Cancellous Bone Grafts
• Three dimensional scaffold
(osteoconductive)
• Osteocytes and stem cells (osteogenic)
• A small quantity of growth factors
(osteoinductive)
• Little initial structural support
• Can gain support quickly as bone is formed
156. Cortical Bone Grafts
• Less biologically active than cancellous bone
– Less porous, less surface area, less cellular matrix
– Prologed time to revascularizarion
• Provides more structural support
– Can be used to span defects
• Vascularized cortical grafts
– Better structural support due to earlier incorporation
– Also osteogenic, osteoinductive
• Transported periosteum
157. Bone Marrow Aspirate
• Osteogenic
– Mesenchymal stem cells (osteoprogenitor cells)
exist in a 1:50,000 ratio to nucleated cells in
marrow aspirate
– Numbers decrease with advancing age
– Can be used in combination with an
osteoconductive matrix
158. Autograft Harvest
• Cancellous
– Iliac crest (most common)
• Anterior- taken from gluteus medius pillar
• Posterior- taken from posterior ilium near SI joint
– Metaphyseal bone
• May offer local source for graft harvest
– Greater trochanter, distal femur, proximal or distal tibia,
calcaneus, olecranon, distal radius, proximal humerus
159. Autograft Harvest
• Cancellous harvest technique
– Cortical window made with osteotomes
• Cancellous bone harvested with gouge or currette
– Can be done with trephine instrument
• Circular drills for dowel harvest
• Commercially available trephines or
“harvesters”
• Can be a percutaneus procedure
160. Autograft Harvest
• Cortical
– Fibula common donor
• Avoid distal fibula to protect ankle function
• Preserve head to keep LCL, hamstrings intact
– Iliac crest
• Cortical or tricortical pieces can be harvested in shape
to fill defect
161. Bone Allografts
• Cancellous or cortical
– Plentiful supply
– Limited infection risk (varies based on processing
method)
– Provide osteoconductive scaffold
– May provide structural support
162. Bone Allografts
• Available in various forms
– Processing methods may vary between companies
/ agencies
• Fresh
• Fresh Frozen
• Freeze Dried
163. Bone Allografts
• Fresh
– Highly antigenic
– Limited time to test for immunogenicityor
diseases
– Use limited to joint replacement using shape
matched osteochondral allografts
164. Bone Allografts
• Fresh frozen
– Less antigenic
– Time to test for diseases
– Strictly regulated by FDA
– Preserves biomechanical properties
• Good for structural grafts
165. Bone Allografts
• Freeze-dried
– Even less antigenic
– Time to test for diseases
– Strictly regulated by FDA
– Can be stored at room temperature up
– to 5 years
– Mechanical properties degrade
166. Bone Graft Substitutes
• Mechanical properties vary widely
– Dependant on composition
• Calcium phosphate cement has highest compressive
strength
• Cancellous bone compressive strength is relatively low
• Many substitutes have compressive strengths similar to
cancellous bone
• All designed to be used with internal fixation
167. Grafting of the Extraction Socket
• The teeth are extracted atraumatically
preserving the buccal bone.
• All granulation tissue is excised with the use of
a surgical curette or a Rongeur.
168. Bone Morphogenetic Proteins
• Produced by recombinant technology
• Two most extensively studied and
commercially available
– BMP-2 (Infuse) Medtronics
– BMP-7 (OP-1) Stryker Biotech
169.
170.
171.
172.
173.
174. Harvesting Techniques III
Cortical Onlay Bone Graft
• Inadequate buccal to lingual/palatal width
• Autogenous bone: donor sites-mandibular
symphysis, mandibular ramus, calvarium or
iliac crest
• Allografts: demineralized freeze dried bone
allograft blocks, freeze-dried blocks, and/or
particles
175. Interpositional Ridge Graft
• The approximate depth of the osteotomy
should be 1cm.
• A bibevel chisel is used to gently outfracture
the buccal plate and allow enough width for
the proposed implant
• Split ridge technique
