Dental Implantology / /certified fixed orthodontic courses by Indian dental academy

DENTAL IMPLANTS

INDIAN DENTAL ACADEMY

Leader in continuing dental education
www.indiandentalacademy.com

Classification of Implant
According to Leonard. R.Rubin
Classified according to the tissue into which they are
embedded or on which they rest:
Intraosseous implants: Receiving primary support from
within bone
Subperiosteal implants: resting on the bone beneath the
periosteum
Transosseous implants: stabilized by penetrating
through both cortical plates
Transcanal: support from an implant placed through the
tooth root canal into the bone beyond the apex



According to Charles. A.Babbush
There are five main types:
• Mucosal Inserts
• Subperiosteal Implants
• Endodontic Implants
• Endosseous Implants
• Transosteal Implants
According to Dennis C. Smith,
David.F.Williams
• Buried: Metals
Non-Metals
Metals: Magnets placed in the superior aspect of the
body of the mandible and another set placed in the
lower denture


Endodontic Stabilizers: Metal rods cemented into
root canal of a natural tooth and extends beyond apex
into the bone
Non-metals: In ridge augmentation and facial
recountouring procedures using proplast, ceramics
and plastics
Also in ridge maintenance efforts by placing
implants made of carbon into recent extraction site
root sockets
• Semi-Buried:
All true dental implants fall into this category
Metals: Cobalt, Chromium, Molybdenum
Non-metals: Ceramics, Bioglass, Carbons, Plastics

Classification of Implant
Biomaterials

According to Charles A.Babbush, Carl. E. Misch
• Metals and Alloys
• Ceramics and Carbon
• Synthetic Polymers and Composites
Metals and Alloys:
 Titanium
 Co-Cr-Mo based alloy
 Iron-Chromium-Nickel based alloy
 Other metals

 Tantalum
 Platinum
 Iridium
 Gold

 Palladium
 Zirconium
 Hafnium

 Tungsten

Ceramics: Bioactive and Biodegradable
Ceramics based on Calcium Phosphates
Metallic Oxide Ceramics:
 Aluminium Oxides
 Trocalcium Phosphates

 Calcium Aluminates

 Zirconium Oxide (Zirconia)
 Titanium Oxide (Titania)

Synthetic Crystalline Structures like
Hydroxyapatite
Carbons :
 Pyrolytic carbon
 Polycrystalline Vitreous Carbon
 Carbon-Silicone interstitial combination
Synthetic Polymers:
 Polyethylene Terepthalate (PET)
 Polymethyl Methacrylate (PMMA)

 Ultra-high Molecular weight polyethylene

(UHMW-PE)
 Polypropylene
 Polysulfone
 Polydimethyl siloxane or silicone rubber
 Polytetrafluoro ethylene
Composites:
Bioresorbable polymers like
 Polyvinyl alcohol
 Polyacids or glycosides
 Cyanoacrylate

According to Stephen.D.Cook; Jeanette. E.Dalton
(Based on Tissue Response and Systemic
Toxicity)
Biotolerant
Bioactive
Bioinert


Implant Systems
 IMZ Dental Implant Systems
 Innova Endopore Implant System
 Nobel Biocare and 3i Systems
 Sulzer-Calcitek Implant System
 Friatec and Frialit
 Oratronics Spiral
 Implant Innovations incorporated


IMZ Dental Implant Systems


 It consists of a cylindrical, endosseous

implant; a highly polished transmucosal
implant extension (TIE), and a viscoelastic
intramobile element (IME)
 This has been in use since 1978
 It is made of commercially pure titanium
 The outer surface is titanium plasmasprayed with an electric arc, which gives
rough texture and a large surface area
 Apical end of implant contains vent for
bone ingrowth

 They are available in 3.3, 4.0 and 4.25 mm

diameter and in lengths of 8,11,13,15,17, and
19 mm
 The Transmucosal Implant Extension (TIE) is
an highly polished titanium sleeve that sits on
top of the implant and extends up through the
soft tissue
 Designed to be easily cleaned in situ by patient
and can be removed by dentist for extraoral
cleaning
 The Intramobile Element (IME) is made up of
polyoxymethylene and provides a resilient
connection between the implant and prosthesis

4 mm implants in lengths 8,11,13
and 15 mm. placement head
assemble, titanium healing screw,
second-phase sealing screw and
TIE, IME and TIE,


 They are developed by Interpore

International, Irvine
 Indicated in totally edentulous, partial
edentulous, class I and II and single tooth
edentulous space
 IME is designed to minimize stress
concentrations, by absorbing and
distributing occlusal surfaces
 Abutments systems are two: the
conventional TIE and IME ; the intramobile
connector (IMC)

Completely edentulous patient
rehabilitation


(1) custom tissue bar
and clip-on
overdenture




(2) custom milled
tissue bar and
precision overdenture




(3) implant supported,
electively retrievable
fixed prosthesis
(bone-anchorage
bridge)


For partially edentulous patients
 Implant is rigidly connected to the natural

tooth using an extracoronal screwstabilized attachment
 Indicated for maxillary and mandibular
posterior edentulous situations
 It distributes load between the implant and
the natural abutment
 Possible if an semiprecision or telescopic
attachment is used to connect teeth to
implants

 Single-tooth abutment has been designed

for use with IMZ implant
 In anterior regions of the mouth
 This titanium abutment is a two-piece
insert
 Transmucosal section tightened against
top of the implant body






Prefabricated
ceramicor post and
ring on the right
designed so that
when seated into
abutment on left, post
fits precisely over
coronal aspect of
abutment
crown secured by
using cement


Noble Biocare and 3i Systems
 Both systems are similar
 Packaged differently: glass tube and blister

pack
 Various coating like hydroxylapatite and
titanium plasma spray are available
 Diameters– 3.75, 4, 4.5, 5, and 5.5 mm
 Branemark instrument names are used
 Procedure begins with guide drill to half its
diameter at propos implant site
 2-mm twist drill to final implant depth

 Counterbore to enlarge the coronal portion of

osteotomy in preparation for 3-mm twist drill
 3-mm twist drill
 Counter-sink drill
 Depth gauge
 Screw tap
 Insert implant attached to fixture mount
 Wrench stabilizes fixture mount while fixation
screw is removed
 Cover screw inserter
 Cover screw placement with small hexagon
screwdriver

Seat Nobel Biocare implant so that
its cover screw is flush with crest of
bone


Sulzer-Calcitek Implant System
 Available in 3.25, 4, and 5 mm diameters

 Principles applied can be used for other press-

fit endosseous cylindrical implants
 Pilot drill for a depth of 8 mm
 Rosette bur to half its diameter over the pilot
osteotomy
 Intermediate spade drill to enlarge pilot
osteotomy for final depth preparation
 Counter bore drill to enlarge coronal portion
 Final spade drill
 Implant body try-in





Seat implant with its
plastic cap
Tap implant into
position
Seat calcitek implants
flush with crest of
bone


Innova Endopore Implant
 It has a surface macrostructure of sintered

titanium beads
 This design greatly increases surface area and
encourages high levels of intraosseous
retention
 Technique for seating uses the classic bone
enlargement drill, a steel try-in, and placement
of implant in the press-fit mode


Pilot drill, implant bur, trial fit gauge,
implant placement


Friatec and Frialit 2

 These are stepped screw or press-fit TPS-

coated implants designed to increase primary
stability in poor-quality bone
 Available in 3.8, 4.5, and 5.5 mm diameter
 Primary purchase point with a round drill
 Spade drill or twist drill used to full depth
 Enlarge receptor site to its final diameter using
stepped drill
 Place implant into receptor site, first with finger
pressure and then ratchet them into deeper
threaded environment

Omni-R
 Guide drill at potential implant site
 Pilot drill to full predetermined depth
 Intermediate drill
 R2 Hand auger
 Seat implant in flush with crest of the bone


Oratronics Spiral
 Guide drill used
 Pilot drill or spade drill to its final pre-

determined depth
 Spiral tap is attached to hand ratchet
 Enlarge the osteotomy to chosen length and
width
 Implant attached to titanium insert, placed in
the hand wrench and rotated to its final seating
position

SURGICAL PROCEDURES IN
IMPLANTOLOGY

 Stage I Surgery

also known as fixture installation stage, is the
procedure for installing Branemark system
implants into bone. This procedure demands
exacting, non-traumatic preparation of the
recipient site and a specific insertion protocol.
Variations in this procedure mainly depends on
the quality and quantity of bone and also on the
load demands on the final prosthesis

High speed hand piece geared up
to run at high torque with a speed
of 1500 to 2000 RPMs, and the
slow speed hand piece at high
torque with speed of approximately
15 to 20 RPMs


Drills used for bone preparation
include: guide drill, 2 mm twist drill,
pilot drill, the 3 mm twist drill, and
countersink


Irrigation unit is used to deliver an
even, steady flow of sterile water to
the surgical site at all times during
high and low speed preparation


Surgical guide stent is placed in the
area to project the future position of
the fixture


Guide drill is the first drill used in
the bone preparation process. It is
designed to penetrate the cortical
layer of the bone


Initial penetration using surgical
guide stent, is initiated using high
speed guide drill at 1500 RPM.
Copious saline irrigation used at all
times


2 mm twist drill is used second in
the sequence to prepare the site to
2mm in diameter


Site is progressively enlarged to
2mm with a 2mm twist drill at 1500
RPM


Pilot drill is used next. Inferior
portion of the drill is to engage the
2mm prepared site and superior
portion begins the enlargement of
the site


Final orientation and inclination of
the fixture is by using the pilot drill
at high speed, high torque. It has
an 2mm non-cutting edge and a
3mm cutting edge


3 mm twist drill is fourth drill in bone
preparation. Its used to prepare
bone to its final destination


Implant site is prepared to final
length and width utilizing a 3mm
twist drill operating at high speed


Countersink is the final drill used in
the high speed drilling process. It is
used to create a shelf in the
prepared bony site


Crestal bone carefully prepared
using countersink. Allows superior
aspect of fixture to be placed
crestally or sub-crestally, to avoid
premature loading of the fixture
during stage I healing


Bone tap is the first in the series of
slow speed bone preparation.
Made of titanium and used to
thread the bone prior to implant
placement


Receptor site is tapped utilizing a
titanium tap operating at 15 to 20
RPMs along with copious irrigation


Fixtures are composed of
commercially pure titanium and
range in length from 7 to 20 mm
and width of range 3.75 and 4.0
mm


Fixture mount is connected to the
fixture


Connection to handpiece is used to
connect the fixture mount to the
handpiece


Fixture is connected to the
handpiece, and inserted to the pretapped site at 15 to 20 RPMs


Fixture is in position with
connection t handpiece still
connected


Cylinder wrench used for final
tightening of fixture


Open end wrench to stabilize the
fixture during removal of fixture
mount


Machine screwdriver used to
unscrew the fixture mount from
fixture


Subcrestal position of the fixture


Screwdriver, either hexagonal or
slotted used to place cover screw
into fixture


Cover screws are available either a
hexagonal or slotted configuration


Coverscrew picked up in slow
handpiece and placed into the
fixture


Appearance of fixture after insertion
of cover screw


Sutures placed


Osseointegration
Osseointegration implies that “it is a contact
established without interposition of non bony
tissue between normal remodeled bone and an
implant at the light microscopic level, entailing a
sustained transfer and distribution of load from
the implant to and within the bone tissue".
(Strock & Branemark 1939)
Osseointegration was defined as “a direct
anchorage to an implant body; which can
provide a foundation to support a prosthesis. It
has ability to transmit occlusal forces directly to
bone” (Branemark 1983)

Osseointegration can also be defined as “a
direct structural and functional connection
between ordered, living bone and the surface
of a load carrying implant” (Branemark 1985)
“Osseointegration is an apparent direct
connection of an implant surface and host
bone without intervening connective tissue”
GPT 1987
Fibro-osseous Retention can be defined as
“tissue-to-implant contact with interposition of
dense, healthy collagenous tissue between
the implant and bone” (Misch)

Mechanism of osseointegration
 Similar to primary bone healing

 Initially, blood present between fixture and

bone
 Blood clot formed
 Blood clot is transformed by phagocytic cells
such as polymorphonuclear leukocytes,
macrophages etc
 Most active during 1st and 3rd day of surgery
 Procallus formed containing fibroblasts,
fibrous tissue and phagocytes
 This is differentiated into osteoblasts and
fibroblasts

Photomicroradiographs showing
bone ingrowths after 12 weeks


 This connective tissue is callus
 Osteoblasts form osteogenic fibers which can

calcify
 New bone matrix is formed and is known as
bone callus
 Increase in density and hardness and
remodeling takes place
 Occlusal stresses stimulate surrounding bone
to remodel and osseointegration takes place
 Osseointegrated fixtures are surrounded by
cortical and spongy bone

Photomicroradiographs showing
bone ingrowths in HA coated and
non-coated implants


Stage II surgery


Uncovering of
implants may be after
3 to 4 months of
healing in mandible
and 5 to 6 months in
case of maxillae


Cover screw is exposed after
removal of overlying bone or soft
tissue


Hexagon cover screw driver used
to remove cover screw from implant
from abutment connection


After 4 months of healing, cover
screw removed


Selection of proper sized abutment
for transmucosal connection


Abutment placed into fixture and
secured with abutment screw


Small or large healing caps used to
prevent debris collection in
threaded portion of abutment screw


Surgical dressing during healing
phase


Tissue response after two weeks


Hex abutment screwdriver to screw
abutment screw into fixture


Abutment placed with help from
screwdriver


Abutment clamp used to prevent
transfer of torque to implant while
connecting abutment screw


Abutment clamp in use


In case of multiple implants, same
procedure is followed


Prosthetic rehabilitation in
Implantology
Components mainly
used in fabricating
prosthesis and
making impression
include the gold
cylinder, the gold
screw, the abutment
replica, the index
coping, and the index
pin

Impression coping is designed with a
machined surface to to fit precisely to
the abutment replica. The central
portion is undercut to facilitate retention
of the impression material


Index pins are available in 10,15
and 20 mm lengths. These are
used to secure the impression
coping to the fixture in the mouth


Impression coping is placed on top
of fixture and is secured by the
index pin


Hole created in the tray for access
to retrieve guide pin after
impressioning


Impression made with an
elastomeric impression material


Abutment replica is an brass
analog of the abutment. Top
surface is identical in shape and
form to the abutment in the mouth


Abutment replica in position in the
impression, secured by the guide
pin


The gold cylinder is secured to the
abutment replica with a slotted gold
screw


Coping has been cast and
resecured to the cast with a gold
screw


A case of failing partially
edentulous situation. Restored
using 3 fixtures as anchorage


Impression made with a suitable
impression material


Impression copings are in position


Wax-up is sprued and cast


Completed fixed prosthesis


The inferior surface of the
prosthesis


Patient restored with mandibular
and maxillary fixed prosthesis


Thank you
Leader in continuing dental education


Dental Implantology / /certified fixed orthodontic courses by Indian dental academy

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