This is the introduction to Dental Implantology

2. I. Definitions
 Oral Implant:
A device or inert substance, biologic or
alloplastic, that is surgically inserted into soft or
hard tissues, to be used for functional or cosmetic
purposes.
 Dental Implant:
A permucosal device which is biocompatible
and biofunctional and is placed within mucosa or,
on or within the bone associated with the oral
cavity to provide support for fixed or removable
prosthetics.

3. Or Dental implant
 Prosthetic device of alloplastic material
implanted in oral tissues beneath the
mucosal or/and periosteal layer, and /or
within the bone to provide retention &
support for a fixed or removable prosthesis
 Made of various biomaterial. Most
commonly made of titanium (most
compatible with human biology)

4. introduction
 Losing tooth/teeth is not new problem
 It is possible to replace teeth that look &
function like natural teeth
 Implant is one of the means of achieving this
through osseointegration (biological adhesion of
bone tissue & titanium)
 Pioneered by prof. Per-Ingvar Branemark in
1952 ( Swedish orthopedics' surgeon)

5. Dental implants

6. Advantages & disadvantages of
implant over conventional treatment
 Implants do not involve preparation of the
adjacent teeth, they preserve the residual
bone, and excellent aesthetics can be
achieved.
 However, it is expensive, the patient
requires surgery, time consuming, and
technically complex.

7. III. Types of dental implant
1. Mucosal Insert
2. Endodontic Implant (Stabilizer)
3. Sub-periosteal implant
4. Endosteal or Endosseous implant
 Plate-form implant
 Ramus-frame implant
 Root-form implant
5. Transosseous implant

8. 1. Titanium Mucosal Insert

9. 2. Endodontic Implant (Stabilizer)
Endodontic implants are similar to
prosthodontic implants in many respects.
However, they serve another purpose—the
stabilization and preservation of remaining
natural teeth, not the replacement of lost
teeth.

10. 3. Sub-periosteal implant
Subperiosteal Implants were already introduced in
the 1940s. Of all currently used devices, it is the
type of implant that has had the longest period of
clinical application. These implants are not
anchored inside the bone, such as Endosseous
Implants, but are instead shaped to ride on the
residual bony ridge of either the upper or lower
jaw. They are usually not considered to be
osseointegrated implants.
Subperiosteal Implants have been used in
completely edentulous as well as partially
edentulous upper and lower jaws. However, the
best results have been achieved in treatment of the
edentulous lower jaw.

11.  Indications:
Usually a severely resorbed, completely
edentulous, lower jaw bone which does not
offer enough bone height to accommodate
Root form Implants as anchoring devices.

12. 5. Endosteal or Endosseous implant
A. Plate-form implant :
Blade Implants have a long track
record, much longer than the Root form
Implants. Their name is derived from
their flat, blade-like (or plate-like)
portion, which is the part that gets
embedded into the bone.

13. Blade implants are not used too frequently
any more, however they do find an
application in areas where the residual bone
ridge of the jaw is either too thin (due to
resorption) to place conventional Root form
Implants or certain vital anatomical
structures prevent conventional implants
from being placed. Nowadays, if a certain
area of the jaw bone is too thin and has
undergone resorption due to tooth loss it is
recommended to undergo a Bone grafting
procedure, which re-establishes the lost
bone, so that conventional Root form
Implants can be placed.

15. Ramus-frame Implants belong in the category of
endosseous implants, although their appearance
might not suggest that at first.
These implants are designed for the edentulous
lower jaw only and are surgically inserted into the
jaw bone in three different areas: the left and right
back area of the jaw (the approximate area of the
wisdom teeth), and the chin area in the front of the
mouth.
The part of the implant that is visible in the
mouth after the implant is placed looks similar to
that of the Subperiosteal Implant.
B. Ramus-frame implant

17.  Indications:
Usually a severely resorbed, edentulous
lower jaw bone, which does not offer enough
bone height to accommodate Root form
Implants as anchoring devices. These
implants are usually indicated when the jaws
are even resorbed to the point where
Subperiosteal Implants will not suffice
anymore.
Ramus-frame implant

18. An additional advantage that comes with
this type of implant is a tripodial
stabilization of the lower jaw. A jaw as thin
as the one shown above can easily fracture at
its thinnest part. The Ramus-frame Implant,
once integrated (after a three month waiting
period) will also stabilize and protect the jaw
somewhat from fracturing.

19. The Ramus-frame Implant usually comes in a
standard pre-shaped form and needs to be custom-
fitted to the patient's individual jaw dimension, as
shown below:

20. Ramus-frame implant

21. C. Root form implant
Since the introduction of the
Osseointegration concept and the Titanium
Screw by Dr. Branemark, these implants
have become the most popular implants in
the world today.

22. Root form Implants come in a variety of shapes,
sizes, and materials and are being offered by many
different companies worldwide. Some clinicians
regard them to be the Standard of Care in Oral
Implantology.
These implants can be placed wherever a tooth
or several teeth are missing, when enough bone is
available to accommodate them. However, even if
the bone volume is not sufficient to place Root
form Implants, Bone grafting procedures within
reasonable limits should be initiated, in order to
benefit from these implants.

23. Root form implant shape:
Other variations dwell on the shape of the
Root form implant. Some are screw-shaped,
others are cylindrical, or even cone-shaped
or any combination thereof.

24. Today, the most accepted material for dental implants is
high grade Titanium—either CP Titanium or an alloy
thereof. The titanium alloy implants tend to be stronger
than the CP titanium implants. The bone integration shows
no difference to the two different types of titanium.
Some implants have an outer coating of
Hydroxyapatite (HA). Other implants have their surface
altered through plasma spraying, or beading process. This
was developed to increase the surface area of the titanium
implant and, thus, in theory, give them more stability.
These surface treatments were also offered as an alternative
to the HA coatings, which on some implants have shown to
break loose or even dissolve after a few years.

25. 6. Transosseous implant
These implants are not in use that much any
more, because they necessitate an extraoral
surgical approach to their placement, which again
translates into general anesthesia, hospitalization
and higher cost, but not necessarily higher benefits
to the patient.
In any case, these implants are used in
mandibles only and are secured at the lower border
of the chin via bone plates. These were originally
designed to have a secure implant system, even for
very resorbed lower jaws.

26. A typical Transosseous Implant. The plate on the bottom is
firmly pressed against the bottom part of the chin bone,
whereas the long screw posts go through the chin bone, all
the way to the top of the jaw ridge inside the mouth. The
two attachments that will eventually protrude through the
gums can be used to attach an overdenture-type prosthesis.
The plate
long screw posts
The two attachments

27. IV. Osseointegration
 Definition:
A time-dependant healing process
where by clinically symptomatic rigid
fixation of alloplastic materials is achieved,
and maintained, in bone during functional
loading. (Zarb & Albrektson,1991)

28. Factors affecting osseointegration
1. Implant biocompatibility
2. Implant design
3. Implant surface
4. Implant bed
5. Surgical technique
6. Loading condition

29. 1. Implant biocompatibility
 Materials used are:
 Cp titanium (commercially pure titanium)
 Titanium alloy (titanium-6aluminum-
4vanadium)
 Zirconium
 Hydroxyapatite (HA), one type of calcium
phosphate ceramic material
 Osseointegration interface:
 Osseointegration
 Biointegration

30. 2. Implant design (root-form)
 Cylindrical Implant
Some investigators explain the lack of bone
steady state by overload due to micromovement
of the cylindrical design, whereas others
incriminates an inflammation/infection caused
particularly by the very rough surfaces typical
for these types of implant.
 Threaded Implant
In contrast, Threaded implants have
demonstrated maintenance of a clear steady
state bone response.
To enhance initial stability and increase surface
contact, most implant forms have been
developed as a serrated thread.

31. 3. Implant surface
Pitch, the number of threads per unit length, is
an important factor in implant osseointegration.
Increased pitch and increased depth between
individual threads allows for improved contact area
between bone and implant.
Moderately rough surfaces with 1.5µm also,
improved contact area between bone and implant
surface.
Reactive implant surface by anodizing (Oxide
layer) ,acid etching or HA coating enhanced
osseointegration

33. Bone Quality
 Quality I
Was composed of homogenous compact bone, usually found in the
anterior lower jaw.
 Quality II
Had a thick layer of cortical bone surrounding dense trabecular bone,
usually found in the posterior lower jaw.
 Quality III
Had a thin layer of cortical bone surrounding dense trabecular bone,
normally found in the anterior upper jaw but can also be seen in the
posterior lower jaw and the posterior upper jaw.
 Quality IV
Had a very thin layer of cortical bone surrounding a core of low-
density trabecular bone, It is very soft bone and normally found in the
posterior upper jaw. It can also be seen in the anterior upper jaw.
According to Lekholm and Zarb.,1985

34. 5. Surgical technique
Minimal tissue violence at surgery is essential for
proper osseointegration.
 Careful cooling while surgical drilling is performed at
low rotatory rates
 Use of sharp drills
 Use of graded series of drills
 Proper drill geometry is important, as intermittent
drilling.
 The insertion torque should be of a moderate level
because strong insertion torques may result in stress
concentrations around the implant, with subsequent
bone resorption.

35. 6. Loading condition
 Delayed loading:
1. A tow-stage surgical protocol
2. One-stage surgical protocol
 Immediate loading:
1. Immediate occlusal loading (placed within 48 hours
postsurgery)
2. Immediate non-occlusal Loading (in single-tooth or
short-span applications)
3. Early loading (prosthetic function within two months)

36. V. Biomechanics of
osseointegrated implant.
In all incidences of clinical loading, occlusal forces are first
introduced to the prosthesis and then reach the bone
implant interface via the implant. So far, many researchers
have, therefore, focused on each of these steps of force
transfer to gain insight into the biomechanical effect of
several factors such as
 Force directions and magnitudes,
 Prosthesis type,
 Prosthesis material,
 Implant design,
 Number and distribution of supporting implants,
 Bone density, and
 The mechanical properties of the bone-implant interface.

37. Dental Implant Treatment Planning and
Types of Dental Implants
 How many teeth are missing?
 What is the degree of bone loss?
 Are the remaining teeth in a good position
and do they have a long-term prognosis?
 What does the patient expect for an end
result?
 What treatment will result in the best
cosmetic outcome?
 What is the patient's budget?

38.  Overall...
What is the most practical
and feasible implant treatment that will
produce optimal chewing function and
optimal cosmetic results in a timely and
affordable manner?

39. Super structure:
 It could be defined as a metal
framework that fits the implant
abutments and provides retention for
the prosthesis. Recently, it is defined
as the superior part of multiple layer
prosthesis that includes the replaced
teeth and associated structures

40. Diagnosis and
Treatment Planning
 The evaluation of a patient as a suitable
candidate for implants should follow the same
basic format as the standard patient
evaluation, although some areas require
additional emphasis and attention:
I. Medical History.
II. Psychological Status.
III. Dental History.

41. I. Medical History
The patient’s medical history may reveal a
number of conditions that could complicate or even
contra-indicate implant therapy. These include:
1. Bleeding disorders; Paget’s disease; A history of
radiation therapy in the maxilla or mandible region;
Uncontrolled diabetes; Epilepsy that presents with
more than one grand mal seizure per month;
2. In addition, there are a host of systemic medical
conditions, including steroid therapy,
hyperthyroidism, and adrenal gland dysfunction
3. Substance abuse including tobacco and alcohol

42. II. Psychological Status
If the patient cannot come to
terms with the possibility of failure, or
four to six months of potential
discomfort and inconvenience, then
he or she is not a suitable candidate
for implant therapy.

43. III. Dental History
It is also vital to evaluate the patient’s
chief complaint, as it may have an equal bearing
on treatment outcome.
For example, the treatment plan
recommended to the patient desiring a more
secure lower denture will be quite different from
the one proposed to the patient seeking a fixed
and rigid appliance.

44. Implant Guidelines
Diagnostic phase
 Problem list & treatment
considerations
-radiographic analysis
surgical analysis
esthetic analysis

45. Implant Guidelines
Diagnostic phase
radiographic analysis
surgical analysis
esthetic analysis

46. Implant Guidelines
Diagnostic phase
radiographic analysis
periapical pathology
radiopaque/radiolucent regions
adequate vertical bone height
adequate space above inferior
alveolar nerve or below maxillary
sinus

47. Implant Guidelines
Diagnostic phase
 Problem list & treatment
considerations
radiographic analysis
adequate interradicular area
bone quality & quantity
radiographs - panoramic and
periapical (CT scan or tomography -
as indicated)

48. Implant Guidelines
Diagnostic phase
radiographic analysis
radiographs - aid to determine
amount of “space”& bone available
 CT (computed tomography) scan -
gives more accurate & reliable
assessment of bone (quality,
quantity & width) & locale of
anatomic structures

49. Implant Diagnostic
Guidelines
Diagnostic phase
radiographic analysis -
radiographic stent - (can double as
surgical stent)
 acrylic stent with lead beads or ball -
bearings (5mm) placed in proposed
fixture locations
 allows more accurate radiographic
interpretation

50. Implant Guidelines
Treatment planning phase
 Problem list & treatment
considerations
surgical analysis -
implant length/diameter
 determined by quantity of bone apical
to extraction site
 use longest implant safely possible
 diameter dictated by corresponding
root anatomy at crest of bone

51. Implant Guidelines
 Treatment planning phase
 Problem list & treatment considerations
 surgical analysis
 treatment options
 immediate - place implant at time of tooth
extraction
 delayed immediate - 8-10 week delay
 delayed - 9-10 months or longer
 immediate will not allow bone resorption, but
delayed allows bone fill for stabilization

52. Implant Guidelines
 Treatment planning phase
 Problem list & treatment considerations
 surgical analysis
 proper surgical technique during implant
placement is critical
 minimal heat generation important

53. Treatment planning phase
 Problem list & treatment
considerations
radiographic analysis
surgical analysis
esthetic analysis

54. Treatment planning phase
 Problem list & treatment
considerations
esthetic analysis
implant emergence profile
 restored implant should appear to
“grow” or emerge from the gingiva
 very natural & desirable in
appearance

55.  Treatment planning phase
 Problem list & treatment considerations
 esthetic analysis
 smile line - high in maxilla; low in mandible
 lip shape - full Vs. thin
 existing ridge defect - if visible with high smile
line will need augmentation

56. The superstructure for completely
edentulous patients can be classified
as follows:
A. Implant retained removable overdenture
B. Implant supported removable overdenture
C. Fixed detachable prosthesis (Hybrid
prosthesis)
D. Implant supported Fixed Bridge
E. 1) Screwed-in Fixed Bridge
2) Cemented Fixed Bridge

57. Design Concepts for
Removable Implant Prostheses
Removable options can now
be either nonrigid (resilient) or rigid. A
removable rigid overdenture will
function in a similar manner as a fixed
implant prosthesis.
Rigid
Resilient

58. Resilient Design
Removable implant prostheses can be restored
using a combined implant-retained and soft
tissue-supported overdenture (ie, the two- implant
overdenture).
Fabrication of this type of restoration can be
completed using individual unsplinted retainers that
allow rotation or a bar-clip prosthesis equipped with
a hinging mechanism for rotation. The use of a bar
(ie, Dolder bar-joint) allows movement between the
two components.
In either case, the classic principles of
complete denture fabrication apply adequate
denture base extension and proper adaptation are
essential. These design concepts should not be
extrapolated to the maxillary arch.

59. Rigid Design
 The implant-retained and implant-supported
removable overdenture (ie, multiple implant bar
overdenture with three or more implants) may or may
not require the same number of implants as the fixed
and usually has multiple retentive elements.
 This type of prosthesis does not, however, contain a
rotational device. The bar used in these types of
restorations is a bar unit (ex, Dolder bar-unit). It
allows no movement between the bar and sleeve.

60. Treatment Plan Selection
Treatment planning and the decision-
making process is a balance between the
patient’s preferences, finances and
clinical factors.
Understanding that cost is an initial
barrier to case acceptance, a large
percentage of patients may reject more
expensive options that only include fixed
prostheses.

61. Clinical factors
Quality, quantity, and shape of supporting alveolar
bone.
The cantilever design can be avoided if the implants
are placed posterior to the foramen. A fixed option
could be utilized but will display less teeth, while a
removable option will provide increased tooth
display. .
A patient who has the bone quality to support a fixed
prosthesis could also be a candidate for an implant
overdenture supported by fewer implants.

62. Extraoral Diagnostic Guidelines
Removable
Fixed
High
Low
Lip line
Distinct
Little
Tooth display
Necessary
No need
Facial/Lip
support

63. Intraoral Diagnostic Guidelines
Removable
Fixed
Buccal
inclination
Buccal convex
Vertical convex
Ridge (shape)
> 15 mm
~10 mm
Intermaxillary
distance
Skeletal
Neutral
Intermaxillary
relationship
Thin, mobile
Thick, keratinized
Mucosa

64. The most common line of
treatment

65. Treatment Planning
Determinants
1. Changes in Oral Structures in
Edentulism
2. Posterior Ridge Anatomy
3. Occlusal Forces
4. Quality, Location and Quantity of Bone
5. Implant Size
6. Implant Location
7. Arch configuration
8. "Mapping" the Mandible
9. Cantilevering

66. 1. Changes in Oral Structures
in Edentulism
With successive denture treatments, it is
common for the vertical dimension of occlusion
to decrease as bone resorbs. This promotes
an increased tendency toward a skeletal Class
III relationship.

67. Posteriorly, poor ridge height,
inadequate attached gingiva and
compromised ridge shape cause
increased horizontal movement of the
prosthesis. This increases the lateral
forces that are brought to bear on the
anterior implants, and will affect bar
and prosthesis design.
2. Posterior Ridge Anatomy

68. Posterior Ridge Anatomy

69. 3. Occlusal Forces
The maximum bite force of subjects with a
mandibular denture supported by implants is
60 to 200% higher than that of subjects with a
conventional denture
Edentulous patients that are predisposed to
clenching and bruxing may be given the
necessary "tools" to begin parafunctional
habits once the implant bar is secured in
place.

70. Occlusal Forces &
Attachments

71. The minimum buccal-lingual thickness of
osseous tissue required to successfully place an
implant is 5 mm.
In order to achieve a 5.0 mm "flat" base, either
the anterior ridge crest peak must be removed or
a bone graft must be considered.
4. Quality, Location and Quantity of
Bone

72. 5. Implant Size
The greater the surface area of the implant-
bone system, the less concentrated the force
transmitted to the crest of bone at the implant
interface. Similarly, the greater the surface area
of the implant-bone system, the better the
prognosis for the implant.
 For each 0.25 mm increase in diameter, the
surface area of a cylinder increases by more
than 10 per cent;
 For each 3.0 mm increase in length , the surface
area of a cylinder increases by more than 10 per
cent.

73. Implant Size
0.25 mm diameter = 3.0 mm length

74. 6. Implant Location
 Ideally, occlusal forces should be directed
along the long axis of the implants. Therefore
,The angle of the osseous ridge crest is a key
determinant of implant angulation.
 the distance between an implant and any
adjacent "landmark" (natural tooth or
another implant), which should be not less
than 2.0 mm.

75. The angle of the osseous ridge crest is a
key determinant of implant angulation.

76. 7. Arch configuration
Mandibular arch forms may be classified as
tapered or square.
 With tapered arch forms, the most posterior
right and left implants in a four-implant
treatment are often placed well around the
"turn" of the arch, creating a "U" shaped
design that is well suited to cantilevering,
 With a square arch, the four implants are
usually placed in a relatively straight line. This
"straight line" bar design is not well suited to
cantilevering.

77. 8. "Mapping" the Mandible
The anterior symphysis can be divided into five
geographic sites:
 A point, 6.0 mm anterior to each mental
foramen, determines the most posterior
boundaries, right and left.
 Another possible implant location occurs at the
midline.
 Two additional sites are chosen on each side
of the midline, spaced equidistantly between
the midline and the respective distal sites.

78. " Mapping" the Mandible

79. 9. Cantilevering
 The number of implants, their respective
lengths and locations, the quality of
bone support, the posterior ridge
anatomy, occlusal forces, and the
opposing dentition are of greater
importance in determining the
appropriate cantilever than a suggested
formula.
 One method is to draw a line through
the most anterior implant, and another
through the two most posterior
implants. The distance between the two
lines can then be measured. A
suggested maximum cantilever would
be 1.5 times this distance.

80. The distance between the
two lines can then be
measured. A suggested
maximum cantilever would
be 1.5 times this distance.

81. Cantilevering

82. Treatment Planning
When all the diagnostic information has been
assembled, a variety of available treatment
options must be assessed:
1. One-Implant Overdenture
2. Two-Implant Overdenture
3. Three-Implant Overdenture
4. Four-Implant Overdenture
5. Five-Implant Overdenture

83. One-Implant Overdentures
Indications:
 The maladaptive or dissatisfied denture
patient who demands greater stability and
oral comfort,
 Elderly patients desiring a more stable
mandibular denture,
 Or, as a minimal implant treatment objective
for the partially edentulous patient with
severely compromised teeth in which
removal would convert a patient to a fully
edentulous state

85.  In the two-implant over-denture, an
attachment is used to greatly enhance the
retentive potential of what is essentially a
tissue-supported prosthesis.
 If only two implants are placed, which are
13mm long or longer, and they are in
dense bone, they can be left as individual
supporting units with little risk.
. Two-Implant Solitary
Overdenture

86. Two-Implant Solitary
Overdenture

88. 2. Two-Implant Bar
Overdenture
If the two implants are 10 mm long or
shorter, or the bone quality is
compromised, then ideally:
 They should be splinted.
 They should be at least 10 mm apart (in
order to allow room for a clip or fastening
mechanism)
 They should be no further than 18 mm
apart in order to limit bar flexure.

89. Two-Implant Bar Overdenture

90. Two-Implant Bar Overdenture

91. 3. Three-Implant
Overdenture
The three-implant overdenture is
still essentially a tissue-
supported prosthesis with
enhanced retention supplied by
the attachment/bar complex.

92. Three-Implant Over-denture

93. 4. Four-Implant
Overdenture
At this level, the prosthesis begins to
derive a larger part of its support and
retention from the implant/bar complex,
and the importance of tissue support
decreases.
 Also, the attachments selected for a four-
implant bar over-denture can be more
rigid, as the torquing forces generated by
the prosthesis will be better tolerated.
 This number allows for some "insurance"
in case one implant fails to integrate.

94. Unsplinted Implant
Overdenture

95. Implant-Bar Overdenture

96. 5. Five-Implant Overdenture
At this level, a prosthesis can be fabricated
that is completely implant supported and
retained, if the AP spread of the implants is
adequate.
The decision to fabricate a bar over-denture
over five implants, rather than a fixed
detachable restoration, usually relates to the
patients’ ability to maintain proper oral
hygiene.

97. Five-Implant Overdenture

98. Five-Implant Overdenture

99. PROSTHETIC
PROTOCOL
 Overdenture abutments were cemented or scrowed
into the implants.
 Pressure indicating paste was placed on each
overdenture ball.
 The denture was seated so that the pressure
indicating paste could mark the exact location of
the overdenture abutments. Then, a recess was cut
into the denture at each abutment location
 The resulting depressions in the mucosal aspect of
the denture were lined with polyvinylsiloxane
material and seated in the patient's mouth.
 The denture was either lined with a lab-processed
material or O-rings were used for retention.

100. Overdenture abutments were
cemented or scrowed into the
implants.

101. Pressure indicating paste
was placed on each
overdenture ball.

102. Then, a recess was cut into the
denture at each abutment location

103. lined with polyvinylsiloxane material and
seated in the patient's mouth.

104. The denture was either lined with a
lab-processed material or O-rings
were used for retention

106. THAN
K YOU Thank You!