3. Introduction
Successful implant treatment is dependent on a coordinated approach
combining careful treatment planning, meticulous surgical technique, and
precise prosthetic restoration.
The typical implant team is composed of a trained surgeon, a trained prosthetic
or restorative dentist, and an experienced dental technician.
6. Implant Components
Cover or Healing Screw
Two-stage surgical approach, prior to suturing, the implant fixture is sealed at
its platform with a low profile, intra-implant cover screw.
9. Pre-Implant Biological and Functional
Concepts
Hard Tissue Interface
Osseointegration; The direct structural and functional connection between organized, living
bone and the surface of a load-bearing implant without intervening soft tissue between the
implant and bone.
Clinically, asymptomatic rigid fixation of an alloplastic material (the implant) in bone with
the ability to withstand occlusal forces
For predictable osseointegration,;
1. A biocompatible material (the implant)
2. Atraumatic surgery (Bone Temp. <47 C)
3. Implant placement in intimate contact with bone
4. Immobility of the implant
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11. The orientation of the connective tissue fibers adjacent to an implant differ from a natural tooth.
This zone of connective tissue has been measured to be 1 to 2 mm in height.
Clinically, Probing depths in a healthy implant would be approximately 1 to 2 mm less than the total
measured dimension from the crest of the sulcus to the alveolar bone crest.
Teeth have a periodontal ligament with connective tissue fibers.
Most connective tissue fibers run in a direction more or less parallel to the implant surface.
Pre-Implant Biological and Functional
Concepts
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13. PREOPERATIVE ASSESSMENT AND TREATMENT
PLANNING
Initial Observations and Patient Introduction; Patient’s observation
Chief Complaint; Goals, Expectations, functional or aesthetic
Medical History and Medical Risk Assessment; Only a few absolute medical contraindications
to implant therapy.
Relative contraindications;
Diabetes
Osteoporosis
Immune compromise (HIV infection, AIDS)
Medications (e.g., bisphosphonates—oral and intravenous)
Medical treatments such as chemotherapy and irradiation (e.g., of the head and neck)
14. Intraoral Examination; implant-focused
The restorative integrity of existing teeth, existing prosthetics
Vestibular depths
Palatal depths, edentulous ridge topography
Periodontal status
Oral lesions, infections, occlusion, jaw relationships, inter-arch space, maximum opening,
parafunctional habits, and oral hygiene.
Soft Tissue; Keratinized
PREOPERATIVE ASSESSMENT AND TREATMENT
PLANNING
15. Radiographic Examination
Periapical
Occlusal
Panoramic
Cephalometric
CT and CBCT.
Cost, availability, radiation exposure, and the type of case.
PREOPERATIVE ASSESSMENT AND TREATMENT
PLANNING
16. Areas of study radiographically include the following:
1. Location of vital structures:
• Mandibular canal
• Anterior loop of the mandibular canal
• Anterior extension of the mandibular canal
• Mental foramen
• Maxillary sinus (floor, septations, and anterior wall)
• Nasal cavity
• Incisive foramen
PREOPERATIVE ASSESSMENT AND TREATMENT
PLANNING
17. 2. Bone height
3. Root proximity and angulation of existing teeth
4. Evaluation of cortical bone
5. Bone density and trabeculation
6. Pathology (e.g., abscess, cyst, tumor)
7. Existence of anatomic variants (e.g., incomplete healing of extraction site)
8. Cross-sectional topography and angulation (best determined by using CT and CBCT)
9. Sinus health (best evaluated by using CT and CBCT)
10. Skeletal classification (best evaluated with the use of lateral cephalometric images)
PREOPERATIVE ASSESSMENT AND TREATMENT
PLANNING
18. Critical measurements specific to implant placement include the following:
1. At least 1 mm inferior to the floor of the maxillary and nasal sinuses
2. Incisive canal (maxillary midline implant placement) to be avoided
3. 5 mm anterior to the mental foramen
4. 2 mm superior to the mandibular canal
5. 3 mm from adjacent implants
6. 1.5 mm from roots of adjacent teeth
PREOPERATIVE ASSESSMENT AND TREATMENT
PLANNING
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22. Maxilla vs. Mandible
The posterior maxilla poses two specific concerns related to implant placement:
1. The quality of bone in this area; less implant stability at the time of placement.
2. The proximity of the maxillary sinus to the edentulous ridge; pneumatization of the sinus,
If there is inadequate bone height, “sinus bump” or “sinus lift” procedure would be necessary
24. Pre-Operative Medications
An oral dose of 2 g penicillin V 1 hour preoperatively or an intravenous dose
of one million units penicillin G immediately preoperatively are effective.
Alternative medications include 600 mg clindamycin orally or intravenously.
No postoperative antibiotic administration is necessary
25. Implant Site Exposure
Flapless surgery
Tissue elevation; sulcular, mid-crestal, and vertical-releasing incisions.
Flapless surgery may be indicated when there is adequate keratinized tissue over an ideal ridge
form.
Mid-crestal incision: Through the keratinized tissue, being sure to get the blade up against the
mesial–distal surfaces of the teeth adjacent to the edentulous space.
Vertical-releasing incision: Using a sharp #15 blade, a curvilinear, beveled (approximately 45
degrees), papilla sparring incision should be made to reduce or eliminate incision scarring.
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29. Surgical Technique
The speed should be set at 1000 to 1500 revolutions per minute (rpm) for the precision and pilot
drills.
All drills should be copiously irrigated
Drilling is done with the precision drill at full speed to a depth of 1 to 2 mm short of the depth of
the intended implant (e.g., 8 mm deep for a 10-mm implant).
The area is irrigated and the 2-mm pilot drill positioned in the exact same location after verifying
the correct angulation.
Once position and angulation are confirmed, the 2-mm pilot drill is run at full speed to the
intended depth of the implant (e.g., 10 mm deep for a 10-mm implant).
The osteotomy is then inspected with a thin instrument for possible bone perforation (e.g., sinus
communication or buccal wall perforation).
Immediately after completing the osteotomy, the speed of the motor is changed to 30 newton
centimeters (Ncm) for the insertion of the implant.
30. Complications
Pain, bleeding, swelling, or infection.
A positioning error resulting in implants placed at a compromised angulation or position
Surgical technique complications such as a tear of the soft tissue flap, poor closure of the incision, or
excessive soft tissue trauma may result in tissue dehiscence, infection, and eventual loss of the implant.
Invasion of critical anatomic structures can create more serious complications.
Invasion of the canal of the inferior alveolar nerve may result in paresthesia (non-painful) or dysesthesia.
If the implant invades the maxillary sinus or the nasal cavity, this may result in an infection.
Incision line opening can occur from inadequate suturing or not having tension-free closure.
Esthetic complications can occur from poor implant positioning or angulation, making proper prosthetic
restoration unrealistic.
Mechanical complications can present as an implant platform fracture because of excessive insertion
torque.
