implantology biologic and clinical aspects / academy of fixed orthodontics

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

Dental implants are becoming an
increasingly important part of everyday
dental practice. Over the last ten years,
implants have evolved from an elective
procedure to a routine treatment. Large
clinical trials have documented the high
success rates of dental implants.

At the same time, implants have become
simpler to place and restore, allowing for
implant treatment to be easily incorporated
into the daily life of general practices.
Implants are becoming standard of care in
many clinical situations.

Clinical And
Biological Aspects
Of Dental Implants

DEFINITIONS /KEY TERMS
HISTORY
CLASSIFICATION
INDICATIONS
CONTRAINDICATIONS
COMPONENTS OF IMPLANTS

OSSEOINTEGRATION
VARIOUS SYSTEMS
HOW TO SELECT AN IMPLANT SYSTEM
GATHERING INFORMATION
PROSPECTIVE SYSTEM
Original Branemark Protocol
Surgical considerations
Protocol for implant placement
CHOICE OF AN IMPLANT
 LENGTH
 DIAMETER
 POSITION

STAGES IN IMPLANT PLACEMENT
STAGE I SURGERY
STAGE II SURGERY
CONCLUSION
REFERENCES

Any object or material, such as an alloplastic
substance or other tissue, which is partially
or completely inserted or grafted into the
body for therapeutic, diagnostic, prosthetic,
or experimental purposes
GPT 8

A prosthetic device made of alloplastic
material(s) implanted into the oral tissues
beneath the mucosal or/and/ periosteal layer,
and on/or within the bone to provide retention
and support for an fixed or removable dental
prosthesis.
A substance that is placed into or /and upon the
jaw bone to support a fixed or removable dental
prosthesis.
GPT 8

Implant
No Cementum and PDL
Blood supply is mainly from
periosteum
TOOTH
Has cementum and PDL
Blood supply is periodontium
and periosteum

Unlike teeth, implants lack
healing capacities.
Implants do not have
periodontal ligament.
The barrier to the oral cavity is
rather different around implants,
principally because of a missing
connective tissue.
Natural tooth Vs implantsNatural tooth Vs implants

HISTORICAL REVIEWHISTORICAL REVIEW

500 BC – Etruscan population

600 AD – Mayan population
“First evidence of use of implants”

1700 – John hunter → “Transplantation”
Transmission of various diseases

1809-Maggiolo
Gold roots
1939-Strock
Vitallium screw

1943 - Dahl 1948 - Goldberg and Gershkoff
Subperiosteal implant

1960 – Linkow Blade vent implant

• Inflammatory reaction
• Gradual bone loss
• Fibrous encapsulation

“CONCEPT OF OSSEOINTEGRATION”
Dr. Per-Ingvar Branemark
Orthopaedic surgeon
Professor University of Goteburg, Sweden.
Threaded implant design made up of pure titanium.

Basic research 1952 to 1965 → 13-15 year extensive research
1965 → First clinical evidence of implant insertion
“Edentulous human patient for resorbed edentulous ridge”

Classification of Implants :
1) Sub - periosteal implant
2) Transosteal implant
3) Endosseous implant
4) Endodontic or Diodontic implant
5) Intramucosal implant

Classification :
Based on placement within the tissues
Sub - Periosteal Implants
Transosteal Implants
Endosteal Implants

Sub Periosteal Implant :
an implant that is placed beneath the
periosteum of the bone.
It receives it’s primary bone support by
resting on it.
This implant does not osseointegrate.

Transosteal Implants : an dental implant that penetrates both
cortical plates and passes through the entire thickness of the
alveolar bone.

Endosseous Implant : an implant that
is present within the bone , extends into
basal bone for support.
Types : Screw form
Cylinder form (Hollow,Solid)
Blade form

Endosseous implant
1) Blade form or Plate form
2) Root form implants
Screw ( V-thread, Buttress
thread, Power or square
thread)
Cylinder ( Hollow or Solid ) Endosseous, root
form, screw type,
power thread
Endosseous, root form,
tapered, hollow,
cylindrical,

Depending on the materials used :
a) Metallic Implants :
Titanium
Titanium alloy
Cobalt chromium molybdenum
b) Non - Metallic Implants
Ceramics
Carbon
Depending on their reaction with bone (Meffert)
a) Bioactive HA coated, CaP coated
b) Bio-inert implants Metals

INDICATIONS :
1)Edentulous patient 2) Partially edentulous patient
Conventional complete denture , removable partial denture or
fixed partial denture is not totally satisfactory.www.indiandentalacademy.com

Orthodontic
anchorage

Applications of Osseointegration concept in Maxillofacial prosthesis
Lost his ear after
oncosurgery for
malignant
melanoma
Implants ,
percutaneous
abutments &
dental bar for
retention of the
prosthesis
Appearance after
silicone rubber
prosthesis. TISSUE
INTEGRATED
PROSTHESIS
Maxillofacial prostheses

Scope of osseointegrated implants
1) Prosthetic rehabilitation of missing teeth
Complete edentulous maxilla and mandible rehabilitation.
Removable prosthesisFixed prosthesis

Single tooth replacementPartial dental loss replacement

2) Anchorage for the maxillofacial prosthesis
Auricular Prosthesis

Ocular Prosthesiswww.indiandentalacademy.com

Nasal prosthesis

3) For rehabilitation of congenital and developmental defects
- Cleft palate
- Ectodermal
dysplasia

4) Complex maxillofacial defect rehabilitation
5) Orthodontic anchorage.

Contraindications:
Uncontrolled systemic conditions/ crippling disease.
Diabetes mellitus
Hypertension
Steriod therapy
Smoking
pregnancy
High dose irradiation
Occlusal trauma
psychiatric patients
Lack of muscular co-ordination to manage oral hygiene procedureswww.indiandentalacademy.com

Smoking and osseointegration :
• History of smoking affect the healing response in osseointegration.
• Lower success rates with oral implants
• Mechanism behind
Vasoconstriction
Reduced bone density
Impaired cellular function
• Mean failure rates in smoker is about twice than in non smoker.www.indiandentalacademy.com

Requirements:
Good oral hygiene
Good periodontal health
Restorations done
Adequate bone quality and quantity
Well motivated patient

I ) Metals
• Stainless Steel
• Cobalt Chromium Molybdenum
Alloys
• Titanium and Its Alloys
• Gold
• Tantalum
Biomaterials Used In Implantology:
II ) Ceramics
• Hydroxyapatite Coated
• Bioglases
• Aluminum Oxide
III ) Polymers And
Composites
IV ) Carbons

PROSTHETIC
SCREW
CROWN
PROSTHETIC
ABUTMENT
FIXTURE OR
IMPLANT
Generic terminology of
implants
Root form implants are a
category of Endosseous
implants that are designed
to use a vertical column of
bone, similar to the root of
a natural tooth
• Cylinder root form
implants (tapered) depend
on a coating to provide
microscopic retention &/ or
bonding to the bone
• Screw root form are
threaded into a bone site &
have macroscopic retentive
element for bone fixation

Components of Implants :
IMPLANT BODY
Implant body has 3 parts :
1) Apex region
2) Body
3) Crest module (Smooth area)
Hex
(external)
Crest
module
Body of
the
implant
Apex
region
Implant collar

Attachment mechanism :
External hex : It resides on the platform
Internal hex : It will extend to within the implant body

Functions of hex:
1) Hex basically acts as a retentive mechanism between
implant body and abutment.
2) It also serves as an effective antirotation element.
 Hex area is the weakest area in the entire implant body abutment
connection
 Screw loosenings, fracture of implant components have been
noted with traditional external hex than the internal hex

Cover screw
At the time of insertion of implant
body or stage I surgery, a first stage
cover is placed into the top of the
implant to prevent bone , soft tissue
or debris from invading the
abutment connection area during
healing. If it is screwed into place
its termed COVER SCREW.
Cover screw
Healing screw
First stage cover

Permucosal
extension
A trans epithelial portion known as PERMUCOSAL
EXTENSION is attached as it extends the implant
above the soft tissue & result in the development of
permucosal seal around the implant
Permucosal extension
Healing abutment

Abutment : The abutment is the portion of the implant that supports and / or retains
a prosthesis or implant superstructure.
3 main types depending on how the prosthesis or superstructure is retained to the
abutment
1) Abutment for screw retention : uses screw to retain the prosthesis
2) Abutment for cement retention : uses dental cement to retain the prosthesis
3) Abutment for attachment : uses an attachment device to retain a removable
prosthesis
Abutments can also be
 Straight
 Angled

“The apparent direct attachment or connection of osseous tissue to
an inert, alloplastic material without intervening connective tissue”.
- GPT 8
Structurally oriented definition :
“Direct structural and functional connection between the ordered,
living bone and the surface of a load carrying implants”.
- Branemark and associates (1977)

Histologically :
Direct anchorage of an implant by the formation of bone directly
on the surface of an implant without any intervening layer of
fibrous tissue.
- Albrektson and Johnson (2001)

Clinically :
Ankylosis of the implant bone interface.
-Schroeder and colleagues 1976
“functional ankylosis”
“It is a process where by clinically asymptomatic rigid fixation
of alloplastic material is achieved and maintained in bone during
functional loading”
- Zarb and T Albrektson 1991

Biomechanically oriented definition :
“Attachment resistant to shear as well as tensile forces”
- Steinmann et al (1986).

Endosseous osseointegrated dental implantwww.indiandentalacademy.com

 “ Fibrous integration as tissue to implant contact with
interposition of healthy dense collagenous tissue between the
implant and bone”.
 “Direct bone to implant interface without any intervening
layer of fibrous tissue”.
FIBROINTEGRATION
Vs
Concept of Bony
Anchorage
Branemark (1969)
Concept of soft tissue
anchorage
Linkow (1970), James (1975),
Weiss (1986).
OSSEOINTEGRATION

Fibrosseousintegration Osseointegration

ULTRASTRUCTURE OF OSSEOINTEGRATION
Soft tissue
interface
Cortical
bone
Spongy
bone

ITI Foundation (International Team for Oral Implantology)
Big Names Best Systems
• Deportter Endopore Highest Studies
• Carl Misch Maestro Highest Research
• Willi Schulte Friadent Highest Follow-up
Latest
in Hardware and Software
Latest Innovations
• Branemark System & ITI System

IJP 2004 Quality of dental implants :As of October 2003
80 companies ; 220 implant brands.
Code A or Grade A:
Extensive clinical documentation i.e. more than 4 prospective and /or
retrospective trails. Osseotite,3i implant innovations
Astra tech , Friadent, Endopore
Straumann, ITI, Nobel Biocare
Zimmer
Code B or Grade B: With limited clinical documentation i.e.
less than 4 trails, but of good methodological quality.
Biohorizons, Maestro, IMTEC,
Bicon, Sargonwww.indiandentalacademy.com

Code C or Grade C : less than 4 retrospective or
prospective clinical trails, but they are of poor
methodological quality.
Code D or Grade D : No studies.
80 systems/companies : 10 Grade A
10 Grade B
60 Grade C & Dwww.indiandentalacademy.com

Selecting an Implant system
Gathering information
Investigating a prospective systemwww.indiandentalacademy.com

Branemark’s Original Protocol :
Tooth Extraction 6months Stage I Surgery
or Implant Placement
4-6 Months Osseointegration
Period
Stage II Surgery or
Prosthesis Placement

Drawbacks of Branemark’s Original Protocol
• Long drawn out affair
• Extremely expensive
• Selection Criteria was very strict, so benefit could be passed on
to very few
Osseointegration Was Accepted As a Clinically Achievable,Osseointegration Was Accepted As a Clinically Achievable,
Reproducible Phenomenon.Reproducible Phenomenon.
Nobody Questioned the Concept of Osseointegration, but theNobody Questioned the Concept of Osseointegration, but the
Protocol to Achieve the Same Was Questioned…….Protocol to Achieve the Same Was Questioned…….
Implantology Moved Ahead With These Path breaking StudiesImplantology Moved Ahead With These Path breaking Studies

Challenges to the Branemark, Albrektsson protocol
Osseointegration
histological level
Immobility
Clinically
Branemark
Protocol
Immediate
Loading
“Clean”
Atmosphere
Clinicians could violate the original protocol, but still achieve
Osseointegration

Two types of design options
1) Submerged
2) Nonsubmerged protocol
Submerged Protocol :
A closed healing environment underneath the mucoperiosteal
cover is an absolute prerequisite for osseointegration.
Non- submerged Protocol :
Trans gingival implants penetrating the mucosa from the time of
placement
Transgingival regions of all these are highly polished.www.indiandentalacademy.com

Changing your clinical setup into an implantlogyChanging your clinical setup into an implantlogy
unitunitwww.indiandentalacademy.com

Protocol for implant placement
Meticulous initial evaluation of a potential implant
patient is critical to successful treatment.
Diagnosis includes :
Systemic
Dental evaluation.
Diagnosis :

Preimplant medical evaluation is similar to
any periodontal or oral surgery procedures.
The most common systemic conditions and
implications for dental implants therapy are:
Smoking
Diabetes
Osteoporosis
Age
Head and neck radiotherapy
Immunocompromised patients
Psychological conditions.
Systemic Evaluation

Dental Evaluation
As in any other procedure, a thorough oral
diagnosis must precede the dental evaluation.
General Considerations:
Traditional radiographic surveys such as
panoramic and full mouth series are often needed.
Periodontal charting and caries detection are part
of the early evaluation.

The treatment plan should address control
of diseases prior to considering implant
placement.
Home oral hygiene must be exquisite, and
no implant treatment should be considered
without full patient cooperation.

Arch shapes and sizes
Maximum intercuspation, centric relation, occlusal
interferences
Anterior guidance
General wear facets and other signs of
Parafunctional habits
Interarch relationships
Adjacent teeth
Esthetic evaluation
Diagnostic casts and diagnostic wax-up
Dental examination particularly relevant to
implant therapy

Clinical Evaluation
The clinical examination includes
evaluation of tissue health, attached
gingiva, and ridges.
Ridge mapping
A clinical procedure in which soft tissue
is measured at several locations of an
edentulous ridge. Measurements can be
reported on a drawing or a model to
estimate the width of underlying bone
architecture.

Radiographic Diagnosis
Radiographic measurements are usually
initiated with traditional two-dimensional
methods such as periapical or panoramic
films. However, these methods do not allow
for buccolingual visualization or evaluation
of bone density, and further techniques may
be necessary.

A radiographic method used
to obtain cross sectional images
in which the radiographic
sources and film rotate around
the plane of interest.
Cross-sectional images of
any portion of the maxilla and
mandible can be obtained using
linear tomography.
Linear tomography

(CT scanning) a software assisted
radiographic technique that produces an
exact cross- sectional view of the mandible
or maxilla.
The most advanced radiographic
methodology for dental implant diagnosis is
computed tomography.
Computed tomography

CT images are inherently three
dimensional digital images.
Typically of 512 x 512 pixels with a
thickness described by the slice
spacing of the imaging technique.
The individual element of the CT
image is called a Voxel, which has a
value referred to in Hounsfield
units, that describes the density of
the CT image at that point.

CT Number or Hounsfield Units
- 1000 for Air
+ 1000 for Dense bone
+ 3000 for Enamel
0 for Water

A CT-Scanner showing dough shaped gantry , computerized couch,
microprocessor and TV monitor

X-ray tube
Patient
Detector array
Both the x-ray tube and detector revolve around the patient

Only the X-ray tube rotates, more than 1000 detectors are fixed
X-ray tube
Patient
Fixed detectors

Standard Imaging Planes Used in CT -Scanning.
Axial scan would be perpendicular to the long axis of the body.
Coronal section would be parallel to the long axis of the body.

CBVT – Cone Beam Volumetric Tomography

Classification of bone quality and quantity
Bone volume classifications

IMPLANT LENGTH:
 Implant length is selected according to bone availability.
 Measurement from the crest to a vital structure will give
an approximation of bone height.
 For mandibular posterior areas, it is recommended to
maintain the osteotomy at least 2 mm from the nerve.
CHOICE OF IMPLANT LENGTH, DIAMETER, AND
POSITION

IMPLANT DIAMETER:
Estimate the buccolingual ridge dimension prior to
selecting a diameter, remembering that at least 1
mm of bone buccal and 1 mm of bone lingual of the
implant must remain.
For example, a 6 mm wide ridge is necessary to
place a 4 mm implant.

IMPLANT POSITION:
For posterior teeth, implant angulation should
allow the implant's long axis to emerge from the
center of the occlusal surface.
For anterior teeth, the angulation should allow the
long axis to emerge through cinguli.
Implant placement should not be compromised by
lack of bone width. Bone grafting prior to
placement is preferable to poor placement.

The implant should not touch adjacent roots.
Multiple implants should ideally be placed at
least 3 mm apart.
Multiple adjacent implants should be parallel
whenever possible.

Perforation made in the stent
Palatal view of surgical template
on diagnostic cast with
perforation over the planned
implant sites
Clinical view of the surgical
template in place

Three upper incisors are missing
Removable plastic template in place
to serve as a surgical template
Stent was coined after an English
dentist Charles R. Stent
Also known as
• Collumellar stent
• Periodontal stent
• Skin graft stent
An appliance which is used to
apply pressure to the soft tissues
to facilitate healing and prevent
cicatrisation and collapse.
Surgical stent :A surgical stent
is a prosthetic appliance, which
helps to orient & position the
implantswww.indiandentalacademy.com

Steps involved in implant placementSteps involved in implant placement
FIRST STAGE SURGERYFIRST STAGE SURGERY
1
2
3 4

5
6
7 8www.indiandentalacademy.com

9
10

13 14

17 18

21 22

25 26
27

28

SECOND STAGE SURGERY

1 2

9 10

21 22
23www.indiandentalacademy.com

IMPLANT MAINTENANCE

1.Osseointegration in clinical dentistry – Branemark, Zarb,
Albrektsson
2.Osseointegration and occlusal rehabilitation – Sumiya
Hobo
3.Contemporary Implant Dentistry – Carl E.Misch
4.Endosseous implants for Maxillofacial reconstruction –
Block and Kent
5.Implants in Dentistry –Block and Kent
6.Dental and Maxillofacial Implantology – John. A.
Hobkrik, Roger Watson

7.Endosseous Implant : Scientific and Clinical
Aspects – George Watzak
8.Optimal Implant Positioning and Soft Tissue
management – Patrik Pallaci
9.Osseointegration in craniofacial reconstruction-
T. Albrektssson.
10.Osseointegration in dentistry : an
introduction : Philip Worthington, Brein. R.
Lang, W.E. Lavelle.

Schroeder et al.,(1981).The reactions of bone, connective tissue, and
epithelium to endosteal implants with titanium-sprayed surfaces.
Journal of Maxillofacial Surgery 9,15-25.
Adell et al.,(1981). A 15 year study of osseointegrated implants in
the treatment of edentulous jaw. International journal of Oral
Surgery 6,387-399.
Zarb & Symington (1983).Osseointegrated dental implants:
preliminary report on a replication study. Journal of prosthetic
dentistry 50,271-279.
Albrektsson et al.,(1986).The long-term efficacy of currently used
dental implants: a review and proposed criteria for success.
International journal of Oral and Maxillofacial Implants 1,11-25.

Johansson & Albrektsson. (1987) Integration of screw implants in the
rabbit. A 1- year follow-up of removal of titanium implants.
International journal of 0ral and Maxillofacial Implants 2,69-75.
Zarb & Albrektsson.(1991).Osseointegration –A-requiem for the
periodontal ligament ? Editorial. International Journal of
Periodontology and Restorative Dentistry 11,88-91.
Albrektsson & Sennerby.(1991) State of the art in Oral implants.
Journal of clinical periodontology 18,474-481.
Wennerberg & Albrektsson.(1993) Design and Surface
Characteristics of 13 commercially available oral implant systems.
International Journal of Oral and Maxillofacial Implants 8,622-23

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implantology biologic and clinical aspects / academy of fixed orthodontics

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implantology biologic and clinical aspects / academy of fixed orthodontics