IMPLANTOLOGY BY CHITRACHAKRAVARTHY

1. DR.CHITRA CHAKRAVARTHY
PROF.& HOD DEPT OF OMFS
NAVODAYA DENTAL COLLEGE

2. DEFINITION:
 Implantation refers to the transfer of non living
material into a biological system.
 Dental implantology is the term used to describe the
anchoring of alloplastic materials into the jaws to
provide support and retention for prosthetic
replacement of teeth that have been lost.


3.  Replacement of missing teeth by alloplastic materials has been a
constantly progressing field of dentistry.
 carved bone and ivory- esthetic replacements -lacked the
functional purpose
 human and animal teeth
 Hartmann in 1891 -use of screws to fix the denture
 Stock in 1939 used Vitallium alloy to create a dental implant
with a threaded body
 Thorough clinical training
 proper patient selection
 implant selection
 coordinated effort of the oral surgeon, periodontist and
prosthodontist for successful results.

4. INDICATIONS FOR IMPLANTS:
 Completely edentulous patient
 Partially edentulous patient
 Partially edentulous jaw with distal free end situation
 Single missing/extracted tooth
 Replacement of teeth in an edentulous jaw with
opposing natural teeth.

5. patient unable to wear a removable denture prosthesis
due to :
 parafunctional habits such as bruxism
 gag reflex
 Patients not satisfied with removable denture.
 Psychological causes
 Inadequate number of abutment teeth

6. CONTRAINDICATIONS FOR
IMPLANT PLACEMENT
 unvorable intermaxillary relationships
 problematic occlusal and functional relationships
 Pathologic conditions of the jaws: cysts, tumors
 Radiation therapy in the jaw region
 pathologies affecting the oral mucosa: Leukoplakia,
lichen planus
 xerostomia
 macroglossia
 Poor oral hygiene

7. TEMPORARY MEDICAL
CONTRAINDICATIONS
 Acute inflammatory diseases or infections: sinusitis,
bronchitis
 Pregnancy
 Medications: such as anticoagulants,
immunosuppressant etc.
 Poor patient compliance: The patient must be fully
prepared for the procedure

8. GENERAL MEDICAL
CONTRAINDICATIONS
 General nutritional condition
 Metabolic disorders: such as diabetes,
hyperthyroidism
 Hematological disorders
 Cardiac and circulatory disease

9.  Osseous and metabolic disturbances: osteoporosis,
osteogenesis imperfecta
 Collagen disorders: scleroderma, rheumatoid arthritis
 Dental implant as a potential bacterial focus: history
of bacterial endocarditis or with heart valve prosthesis
 presents a high risk of bacterimia due to the dental
implant

10. EXAMINATION OF A PATIENT FOR
IMPLANTS:
 Intraoral examination:
 suitable candidate for implant procedures.
 morphology of the alveolar ridges
 condition of the oral mucosa
 intermaxillary relationships
 general condition of the remaining dentition
 pathology or dysfunction associated with the TMJ
 pathology associated with the maxilla or the mandible

11. Anatomic prerequisites
 Soft tissue condition: After tooth extraction- scar
 Bone availability: Various diagnostic aids
 Height of bone: bone present between the crest of the
alveolar ridge to the opposing anatomic boundaries-
atleast 1-2mm safety margin
 screw type implant is usually 10mm.

12.  Width of bone: measured from the buccal/labial to
lingual/palatal osseous plates atleast 0.5mm must be left
on both
 Mandibular canal:
 Maxillary sinus: alveolar atrophy of the maxilla after
extraction
 pneumatisation
 1-2mm from the maxillary sinus.
 Implant –crown relationship: The length of the prosthetic
crown and the implant should be in a ratio of 1:1 or as close
to this as possible.


13. INVESTIGATIONS:
 Radiographic examination:
 Panoramic radiographs: (OPG
 Periapical radiographs: In addition to panoramic
views, an IOPA with a grid

14.  Lateral cephalogram: This radiograph provides
additional information about the qualitative and
quantitative aspects of the bone especially in the
premaxillary region and in the midline of the
mandible
 Occlusal radiograph: info about cortical, cancellous
bone
 Computed tomography: CT scan:

15.  Measurement of mucosal thickness: This is another way of
measuring the width of the available bone
Study model analysis:
- plaster models
- bite registration
- adjustable articulator
- The position, angulations can be assessed
- maxillomandibular relationship
- interarch distance
- alveolectomy planned if it is inadequate in some regions.

16. PATIENT SELECTION
 most vital step for the success of an implant
 The first visit of the patient to the dental clinic
 A detailed dental and medical history
 dental examination is done
 gain maximum patient cooperation
 a good working rapport
 inform about her present state of dental health
 and alternative forms of therapy


17.  educated regarding implant procedures
 possible complications
 better to be conservative when commenting on the
end results
 prepare the patient for chances of failure.
 When the patient is completely satisfied
 sign an informed consent form.

18. Histopathology
What happens when an implant is placed in bone?
 foreign body - contact with the tissues- foreign body
reaction
 with phagocytic activity and reactive inflammation.
 continue till the foreign body is in some way either
removed or rendered harmless.
 The chronic inflammatory reaction varies in hard and
soft tissues.

19. Osseous healing: Early phase
 preparation of the implant bed
 periosteal, intercortical and endosteal blood vessels are
damaged
 resultant hemorrhage.
 Blood accumulates in the periimplant space.
 blood is rich in fibrin and granulation tissue.
 slowly remodeled
 This fibrous tissue then slowly begins to organize
 ingrowth of pre osteoblasts.
 important for close approximation of the blood clot to the
implant

20.  influx of multinucleated giant cells and macrophages
 The material specific effects are however evident only
one week after the placement of the implant

21. Osseous healing: late phase
 Healing around an implant is seen to be similar to
fracture healing.
 Contact healing
 Gap healing
 Two important factors influence the healing of an
implant:
 Presence of adequate blood supply
 Mechanical stability of the implant.


22.  An adequate blood supply is essential for the initial
 degree of stability influences bone formation
 lack of stability -connective tissue accumulation
 inhibits the ingrowth of capillaries
 differentiation of periimplant cells into fibroblasts or
osteoblasts is also inhibited.
 Movement leads to the formation of connective tissue
instead of bone around the implant. This is known as
fibroosseous integration.

23.  important criteria for the success of the implant.
 term osseointegration has been coined by Branemark
 described as a direct contact between viable bone and
the implant without any intervening soft tissue layer
 When there in soft tissue appostion instead of bone
around an implant surface, it is termed as fibroosseous
integration.

24.  Osseointegration: It has been defined as the light
microscopic direct functional and structural bond
between organized vital bone and the surface of an
inanimate, alloplastic material. Osseous union is
desirable for the success of an implant.

26. Ideal requirements for implant
materials
 non carcinogenic, should not be toxic, and should not
be allergenic or radioactive.
 Biocompatibility: implant is said to be biocompatible
if it elicits only desired or tolerable tissue reactions.
 Mechanical compatibility: adequate mechanical
strength
 Functional components
 Practicality:
 be easy to remove if required.
 It should be sterilisable, and economically feasible

27. Preparation of the implant:
 titanium implants
 Titanium plasma spray coated implants:
 Sandblasting of the implant surface
 Laser induced surface roughening: Excimer laser
 Hydroxyapatite coated implants: accelerates the osseous
healing. It is also believed to improve the interface area
between the implant and the bone.

28. CLASSIFICATION OF IMPLANTS:
 I: Based on its placement in relation to bone:
 Endosteal implants:
 These are implants that are placed completely within
the alveolar and basal bone.
 These implants recieve their support by
osseointegration with the alveolar bone into which
they are placed.
 They can be of different types depending on the shape
that is used: blade type, root form etc.


30. Subperiosteal implants
 These implants are placed just below the periosteum
and rest on sound bone.
 Instead of penetrating the alveolar bone they rest on
its surface.
 They are inserted by a surgical procedure
 posts protruding from the surface of the mucosa.
 These implants are indicated in case of an atrophic

32. Transosseous implants
 used in the anterior region of the mandible.
 It consists of a horizontal plate on which the body of
the implant (pins or staples) are fixed.
 This implant is inserted via an extraoral incision

34. II: Depending on the shape of the
implant:
 Blade type implant: These are wedge shaped implants
 Root form implants: these are made to simulate the
root of a natural tooth.
Cylindrical implant: The implant achieves its stability by
a “press fit” mechanism
Screw type implant: This implant consists of threads -
mechanical fixation.

36. III: Depending on the material
used:
 Metals and their alloys:
 Titanium
 Cr Co Mo alloys
 Tantalum

 ceramics:
 - Calcium phosphate ceramics.
 Aluminium oxide
 Tricalcium phosphate
 Hydroxyapatite

37. THE SURGICAL PROCEDURE:
 The following criteria are essential
 adequate instrumentation, essential equipment and
trained dental personnel
 adequate surgical skill by the dentist
 strict sterilization protocol
 good quality prosthodontics
 Systematic documentation radiographs, photographs
etc.
 a proper system of periodic patient recall
 adequate number of patients requiring implants

38. Basic surgical equipment
 surgical drapes, towel clips, gauze
 mouth mirror, dental explorer
 scalpels
 periosteal elevators, sharp curettes
 flap rertractors
 drills and burs with internal or external cooling systems
 implant system kit including the sterile implant to be placed
 needle holder, suture material
 sutures for preparation of tissues and for cutting sutures
 tissue holding forceps
 mallet
 measuring device
 sterile normal saline

39. TYPES OF PROCEDURES
 Immediate implantation: on the day of extraction of
the tooth
 Delayed implantation: 6-8 weeks following
extraction of the tooth or tooth loss.
 Late implantation: 6 months or more following
extraction or loss of tooth

40. STAGES
 Single stage implant: implant fixture is inserted with
a prosthetic post which extends into the oral cavity
 Two stage implant

41. STEPS IN THE PLACEMENT OF AN
IMPLANT
 Incision
 Reflection of a mucoperiosteal flap
 Drilling of bone and insertion of implant body.
 Uncovering of the implant after healing in phase.
 Prosthetic component placement.
 Loading of implant.


42. Preoperative preparation
 The placement of an implant may be done under Local
anesthesia with or without conscious sedation.
 General anesthesia
 Basic principles of sterilization and asepsis
 The perioral region must be disinfected
 chlorhexidine mouth wash.
 extensive implant procedure preoperative antibiotics
may be considered.

43. Incision
 The flaps should have good vascularity.
 The adjacent anatomical structures must be preserved
 There should be adequate visibility
 There should be good access
 provision for extension of the flap if required.
 flap is replaced, it should cover the entire implant
completely.
 A crestal incision with buccal releasing incisions or a
bucally based flap or lingually based flap may be
planned.

44. Reflection of mucoperiosteal flap
 Once the incision has been placed, the mucoperiosteal
flap is reflected using a periosteal elevator
 Care is taken not to button hole the flap
 Care should also be taken not to strip the bone
excessively

45. Placement of implant:
 The implant size is chosen
 The largest possible implant
 increased surface area to provide additional stability
 gap of atleast 2mm from all important anatomic
structures
 The position and angulation of the implant- stent

46.  relatively high speed (max speed 2000rpm) standardized
steel drills.
 specific sizes corresponding to the size of the implant.
 minimal trauma, the drill is used with very slight axial
force
 copious saline irrigation.
 drill is moved up and down to ensure adequate cooling of
the bone that is being cut.
 distance between 2 implants should be as much as the
diameter of the implant when multiple implants are to be
placed.

47.  Titanium instruments
 A thread cutter or a screw tap
 The precise sized implant is then inserted carefully
using a wrench to tighten it till the surface of the
implant is flush with bone surface.
 Cover screws are placed on the implant body
 The mucoperiosteal flap is replaced and sutured

49. Healing in phase
 3 months mandible, 6 months maxilla
 After about 12 weeks time, the metabolic activity in
that region usually equilibriates between normal bone
resorption and deposition. This then represents the
termination of the osseous healing and can be noted
accurately by scintigraphy.

50. uncovering the implant:
 In a two stage implant
 This is done usually about 3 months after placement of
the implant in the mandible and after 6 months in the
maxilla.
 under local anesthesia.
 Various techniques
 crestal incision
 Use of tissue punch or soft tissue trephine
 Electrosurgical uncovering of the implant.

51.  cover screw is removed gently
 osseous union of the implant is tested.
 periimplant soft tissue is checked.
 if coronal margin is thick, it is thinned out to prevent
pseudopocket formation.
 The transmucosal connector is seated in place and
tightened. A radiograph may be taken to evaluate the
precise positioning of the implant.

53. Prosthetic treatment
 The prosthetic replacement is fabricated to suit the
occlusal configuration as decided by he model
analysis. This is then fixed on to the transmucosal
connector. The implant can now be loaded by
masticatory forces.


55. Optimum abutment number:
 how many implants should be placed to replace the
lost chewing function in a partially edentulous jaw?
 Ante’s law
 Ante’s law states that the sum of the periodontal
surfaces of the abutment teeth must be atleast equal to
or preferably greater than that of the teeth to be
replaced.

56. Follow up care of the patient:
 In the immediate postoperative phase, pain and
swelling.
 ice pack for about 1-2 hours after the procedure.
 Analgesics are prescribed for pain.
 The other instructions are given similar to any other
minor surgical procedure.
 routine follow up

57.  recall examination- check the condition of the osseous tissues
around the implant.
 OPG, IOPA and occlusal views are
 Vertical bone loss may lead to pocket formation and subsequent
infections.
 An implant is considered successful if it does not lose more than
1.5mm of horizontal bone support during the first year after
placement and 0.1-0.2mm in the subsequent years.
 Periimplant soft tissue: The soft tissues are checked for
inflammation, infections, probing depth etc.
 The prosthetic superstructure is checked for occlusion and
stability.
 The patient’s oral hygiene

58. COMPLICATIONS ASSOCIATED
WITH IMPLANTS
 Surgical complications:
 Intraoperative complications:
 Hemorrhage: mandibular canal, maxillary antrum with
breaching the antral lining or if the lingual artery
 Nerve injury
 Perforation into the maxillary antrum: If an oroantral
communication is suspected, appropriate radiographs
are taken and managed accordingly.
 Perforation into the nasal cavity.
 Fracture of the jaw:.

59. Complications due to improper
implant placement technique:
 Osseous dehiscence: less than 3mm.
 Perforation of the cortical platesGuided bone
regeneration or hydroxyapatite to fill the bone defect.
 Damage to adjacent teeth
 Insufficient primary stability

60. Immediate postoperative
complications
 Hemorrhage and Hematoma
 Swelling (edema)
 Infection:
 Wound dehiscence
 Mobility of the implant: This is usually a sign of
infection. The implant is removed immediately to
prevent any further damage.

61. Late postoperative complications
 Periimplant pathology
 Fracture of implant: This may occur as a result of
fatigue or trauma to the implant.
 chronic sinusitis
 Chronic pain: An implant placed too close to a nerve
can cause long lasting pain. May necessitate removal
of the implant.
 secondary nerve damage
 mucosal irritation

62. Prosthetic complications:
 Unfavorable location and axis orientation of the
implant.
 Loosening and fracture of the implant post
 Esthetic complications
 Functional complications
 Implant loss.

63. Other surgical procedures
 mental nerve repositioning
 inferior alveolar nerve repositioning
 sinus lift may be done.