Implant in dentistry Dr. Lama El Banna Fifth-year second semester Al Azhar University Palestine Any Question inbox me here lama1997bana@gmail.com

1. DENTAL
IMPLANTOLOGY
(1)
1

2. INTRODUCTION
AND
FUNDAMENTAL
SCIENCE
2

3. DEFINITION OF DENTAL IMPLANT
“Dental implant is an alloplastic and biocompatible
material placed into (endosseous) or onto
(subperiosteal) the jawbone to support a fixed
prosthesis, or to stabilize removable prosthesis.”
3

4. IMPLANT SUCCESS RATE
• Backed by worldwide studies, research, clinical trials and
documentation, over more than 50 years, the dental implant
has been established as a full-fledged tooth replacement
option.
• The success rate of the implant varies from case to case,
depending on several factors like bone volume, bone density,
soft tissues, force factors, treatment planning and the skill of
the implant surgeon and restoring dentist.
4

5. • Generally, implant therapy is a little more successful in the mandible
than in the maxilla.
• The lower success of the implant in the maxilla compared to the
mandible, is because the maxilla shows poor bone density to stabilize
the implant, lower bone volume because of vertical as well as lateral
bone resorption and sinus pneumatization and facial cantilevering.
• Approximate success rate of the implant in the four regions of jaws:
• anterior maxilla: 90–95%;
• anterior mandible: 95–98%;
• Posterior mandible: 85–95%;
• posterior maxilla: 85–90%.
5

6. BENEFITS OF DENTAL IMPLANTS
• Dental implants offer several benefits over conventional tooth
replacement options like the dental bridge and removable partial to
complete dentures.
1. It prevents bone loss because the implant anchors (osseointegrates)
the jawbone and thus prevents further bone loss.Two implants inserted
20 years back in the
anterior mandible have
maintained the bone
volume and prevented
the further bone loss in
the region while in the
other part of the jaw, the
patient has lost most of
the bony ridge. 6

7. 2. It restores the function and aesthetics of the overall
maxillofacial prosthesis.
3. It offers best and most preferred option for stabilizing loose
dentures
(A and B) Dental implants are the most successful and
preferred option to retain the loose dentures. 7

8. 4. It is thought to be the only option to deliver the fixed
prosthesis where the conventional bridge is not possible
(A–C) In cases where no teeth
or no firm teeth are available to
be used as the abutments to
support the conventional fixed
bridge, the implant is the only
option to deliver a fixed
prosthesis.
(D) Even in the cases where
the dental bridge is possible,
the implant prosthesis should
be preferred as it does not
need to cut down adjacent
healthy teeth and also
prevents further ridge loss.
8

9. 5. It is the strongest and long-lasting treatment for the
replacement of missing teeth.
6. The deep flanges and palatal extension of complete
dentures, which cause substantial discomfort to patients,
can be avoided once the denture is retained over the
implants.
9

10. HISTORY OF
DENTAL
IMPLANTS
10

11. • The history of dental implants is believed to have begun as
far back as in the seventh century.
• In the 1930s, dental implants (in their original form, made of
seashells) were found in Mayan burial archeological sites,
placed in a young woman’s jawbone.
• Modern implants had their origin in the discovery by a
Swedish professor of Orthopaedics named Branemark, who
found that titanium (a very strong and noncorrosive metal)
attached itself to a bone when it was implanted into it.
• During one of his experiments, he embedded titanium devices
into rabbit’s leg bones to study bone healing.
11

12. • After a few months, he tried to remove these expensive
devices and when he could not, he noticed that the bone had
attached itself to the metal.
• He eventually decided that the mouth was far more practical
than the leg for his experiments, as it was easier to watch the
progress and there were more toothless people than people
with serious joint problems.
• He called the attachment of the titanium to the bone
‘osseointegration’ and in 1965 he used the first titanium
dental implant in a human volunteer.
12

13. Swedish Professor Per-Ingvar Brånemark 13

14. 14

15. • Over the next few years, he published a lot of research on the use of
titanium dental implants, and in 1978 he commercialized the
development and marketing of his titanium dental implants.
• Over 7 million implants under his brand name have been placed.
Needless to say, there are other dental implant companies that have
used his patent.
• Looking at the technology involved and the high success rates of dental
implants, it is hard to believe that the history of dental implants goes
back only 40 years.
• It did not take long to realize the enormous potential of this technique.
Dr Branemark began focussing on how he could use osseointegration,
to help humans. During his studies, he found that titanium screws could
serve as bone anchors for teeth.
15

16. • Titanium, researchers came to realize, was the only consistently
successful material for dental implants. Before Dr Branemark’s work,
other doctors had been toying with the idea of dental implants for years.
A most of other metals, including silver and gold, had failed. Even
human teeth (from donors) were tried.
• Dr Branemark continued his studies for nearly three decades. His fellow
scientists were sceptical, so he conducted numerous tests, including
some on humans, before he published his findings in 1981.
• After scientific scrutiny of Dr Branemark’s paper, medical confidence in
the procedure grew. Guidelines for implantology were set during the
Toronto Conference in Clinical Dentistry in 1982.
• The standardization of the process during the conference proved to be
the jump start that the dental implant needed. The public began to
accept that dental implants were safe.
16

17. • Commercial oral implantology grew during the 1980s.
Osseointegration was being used to permanently fix an
individual tooth into the patient’s mouth. Implants proved to
be successful in over 90% of cases. The modern dental
implant had arrived!
• Over the next two decades, technology continued to improve
the process. For instance, slight modifications to the titanium
used decreased healing time. As time goes by and as the
practice of dentistry advances, patients will continue to see
dental implants becoming quicker, easier, and less painful.
17

18. DEFINITION OF OSSEOINTEGRATION
• PI Branemark and associates in 1986 defined the
osseointegration of the implant as “direct structural and
functional connection between ordered, living bone and the
surface of a load-carrying implant.”
• SG Steinemann and associates in 1986 simplified the
definition of osseointegration as “direct contact between bone
and an implant surface.”
18

19. PHASES OF IMPLANT
OSSEOINTEGRATION
• Immediately after the implant is inserted into the jaw bone,
the peri-implant bone passes step by step, through different
phases of histological change, to reach the final stage of
osseointegration of the implant with the surrounding bone.
• In the author’s experience, the clinician should be aware of
these histological changes, as all these can be deciding
factors in the modification of the conventional two-stage
implant treatment protocol to one stage, immediate or early
loading of the implant. 19

20. 20

21. Clinical Evidence Of Successful
Osseointegration
• Implant is not mobile when tested clinically
• Implant is asymptomatic – absence of persistent signs and symptoms,
such as pain, infections, etc.
• Stable crestal bone levels – annual rate of bone loss should be less
than 0.2 mm after the first year in function
• Increasing mineralization of the newly-formed bone at the implant
surface
• Healthy soft tissues
• Absence of peri-implant radiolucency.
21

22. ENHANCEMENT OF RATE AND DEGREE
OF OSSEOINTEGRATION
• Several research studies have been performed to find an
optimal surface treatment to increase mechanical stability and
to improve the contact between bone and implant.
• Many studies provide conclusive scientific evidence that a
roughened titanium implant surface improves bone anchoring
compared to conventionally machined titanium surfaces.
22

23. • The rough surface facilitates migration of osteogenic cells to
the implant surface for de novo bone formation (contact
osteogenesis).
• The local mechanical environment provided by the rough-
surface implant also influences cellular differentiation and
tissue synthesis (distance osteogenesis).
• The rough-surface implants show increased removal forces,
greater and earlier bone implant contact (BIC) percentage,
and improved ultimate osseointegration.
23

24. CONTACT AND DISTANT
OSTEOGENESIS
• After implant insertion, new bone formation begins simultaneously at the
prepared osteotomy wall and the implant surface.
• The new bone synthesis (osteogenesis) which begins at the implant
surface is called ‘contact osteogenesis’ and other synthesis which
simultaneously begins at the osteotomy wall is called ‘distant
osteogenesis’.
• Completion of both osteogenesis processes results in complete new
bone synthesis at the implant – host–bone interface which is finally
called ‘implant osseointegration’ with the jawbone
24

25. Diagrammatic presentation of contact
and distant osteogenesis at the implant
surface–host bone interface.
25

26. OSSEOINTEGRATION VERSUS
OSSEOCOALESCENCE
• The term ‘osseointegration’ is commonly used in conjunction with dental
implants. Osseointegration means that there is no relative movement
between the implant and the surrounding bone.
• Although some investigators believe that there is a chemical integration
between bone and the surface of titanium implants, osseointegration
largely refers to the physical integration or mechanical fixation of an
implant in the bone.
• With purely physical interaction, the interface would be able to withstand
shear forces; however, the interface would not be able to withstand even
moderate tensile forces.
26

27. • The term ‘osseocoalescence’ refers specifically to the chemical
integration of implants in bone tissue. The term applies to surface
reactive materials, such as calcium phosphates and bioactive glasses,
which undergo reactions that lead to chemical bonding between bone
and biomaterial.
• With these materials, the tissues effectively coalesce with the implant.
An example of qualitative evidence of chemical bonding is that fracture
lines propagate through either the implant or the tissue but not along the
interface.
• Osseocoalesced implants exhibit resistance to both shear and tensile
loads. Unfortunately, the term has not found widespread use and
osseointegration still is often used when describing interactions between
bioactive materials and bone.
27

28. • Mechanical integration (i.e. osseointegration) of an implant in
bone provides good resistance to shear forces but poor
resistance to tension.
• Chemical integration (i.e. osseocoalescence) however
provides good resistance to both shear and tensile forces.
28

29. PRIMARY AND SECONDARY IMPLANT
STABILITY
• Osseointegration requires bone apposition on the implant
surface without any micromovement.
• During implant insertion, the stability that the implant achieves
is completely mechanical and is called primary stability of the
implant.
• During the healing period, however, the biological processes
of osseointegration change this to a mixture of mechanical
and biological stability (secondary stability)
29

30. (A and B) Primary and secondary stability curves of an
implant during the transition period when the implant remains
at higher risk of micromovement and fails to osseointegrate
30

31. • Further, during the biological processes of osseointegration of
the implant, the surrounding bone physiologically changes
during the multiple phases of bone resorption and new bone
apposition over the implant surface.
• Any micromovement of the implant during this phase may
lead to the failure of implant osseointegration with the bone.
The primary or mechanical stability changes to secondary or
biological stability, once the osseointegration of the implant is
completed. According to different studies, this process may
take 4–6 months.
31

32. SOFT TISSUE INTEGRATION
• Soft tissue integration around implant superstructures like
transmucosal healing abutment, final abutment, etc. can be
defined as “biologic processes that occur during the formation
and maturation of the structural relationship between the soft
tissues and the transmucosal implant superstructures.”
32

33. • “The establishment of an adequate zone of attached and keratinized soft
tissue with intimate adaptation to transmucosal implant superstructures is
critical for long-term success of the restored implants.”
• The epithelial and connective tissue elements are organized to form a
protective soft tissue seal around the implant superstructures, which serves to
resist bacterial and mechanical challenges encountered in the oral cavity.
• “The functional soft tissue –implant interface is equally as important as
osseointegration for the long-term success of implant-supported prosthesis.”
• Thus, a careful manipulation and preservation of existing soft tissue is
paramount for long-term implant success.
• If the area is devoid of attached and keratinized soft tissue, soft tissue grafting
procedures should be performed to regenerate a healthy, thick, attached, and
keratinized zone of marginal soft tissue (minimum of 3 mm), around the
implant superstructures
33

34. The establishment of an adequate zone of attached and
keratinized soft tissue with intimate adaptation to
transmucosal implant super- structures is critical for long-
term success of restored implants.
34

35. COMPARATIVE ANATOMY OF THE NATURAL
TOOTH AND THE OSSEOINTEGRATED IMPLANT
• Although the dental implant clinically looks like the natural
tooth after restoration, the bone and soft tissue integration to
the implant surface and to its superstructures shows several
biological differences compared to the natural tooth.
• The doctor and the patient should be aware of these
differences to achieve a predictable implant therapy and long-
term maintenance practices
35

36. Diagrammatic presentation of comparative anatomy of
periodontal and peri-implant bone and soft tissue.
36

37. Comparative
anatomic
features of
periodontal
and peri-implant
bone and soft
tissue
37

38. • The natural tooth possesses periodontal ligament space
which not only provides additional nutrient supply to the
periodontal hard and soft tissues for their maintenance and
long-term survival, but also acts as the shock absorber
against undue forces over the tooth.
• The implant which gets directly osseointegrated with the bone
and shows no structure like the periodontal ligament, only
possesses limited sources of nutrient supply to the peri-
implant tissue and also transverses all the occlusal forces
directly to the bone. This often can be the cause of bone
resorption around the implant.
38

39. • Another difference which the doctor should know is that the peri-implant
soft tissue does not show any connective tissue attachments to the
implant collar and its superstructures like the natural tooth, and thus any
physical or chemical injury to the soft tissue sulcus may directly affect
the peri-implant crestal bone and may cause crestal bone resorption.
• For this reason, deliberate sulcular probing around the implant is not
recommended. One point the author would like to emphasize here is
that as described earlier, the peri-implant tissues (bone as well as soft
tissue) receive blood supply from only two sources – from the
periosteum and from the basal bone. They do not have the third source
of blood supply like the natural tooth, which receives blood supply from
the periodontal ligament also; thus, the peri-implant tissue with limited
thickness may find it difficult to survive and may get resorbed.
39

40. DENTAL IMPLANT
DESIGNS AND
SURFACES
40

41. • Based on research and clinical trials, several dental implant designs have
been developed and widely used to provide optimal implant therapy to
patients.
• Researchers in the field of implantology have developed a variety of implant
designs and surfaces to achieve optimal osseointegration with the bone, ease
of placement, immediate placement into extraction sockets, adequate primary
stability of the implant, immediate to early loading protocols, and to provide a
wide range of prosthetic options.
• There are several features in implant design and modified implant surfaces
that are very important for a clinician to know, in order to choose the correct
implant, to learn its placement and restoration protocols, and to provide
maintenance for long-term aesthetics and function.
• Although several implant designs have been developed, implant design
continues to be one of the key fields for research oriented towards improving
the acceptability and success of the implant.
41

42. SUBPERIOSTEAL IMPLANTS
• The “implants which are placed under the periosteum and fixed over the
jaw bone are called subperiosteal implants.” These implants are placed
under the periosteum on the bony ridge that holds the removable or
fixed type of prostheses.
• These implants are preferred in cases of severely resorbed mandibles
where endosseous implants are difficult to place, because of the
compromised dimensions of the bone and the close proximity of the
mandibular canal to the crest of the ridge.
• The success of the subperiosteal implant in treating partial to
completely edentulous patients has been validated by several
publications. The first subperiosteal implant was placed in 1949 by
Gustav Dahl and has been constantly improved in design since then. 42

43. Diagrammatic presentation of subperiosteal implant.
43

44. Fabrication
• After treatment planning, the buccal and lingual full-thickness flaps are elevated to
extend beyond the sulcular depth and an accurate impression of the bony ridge is
made, using a hydrophilic impression material (e.g. polyether).
• The flap is sutured back, the impression is poured with dental stone, and a titanium
framework is fabricated over the replica, which has vertical extensions (abutments)
emerging out of the soft tissue to hold the prosthesis.
• After the soft tissue has healed, the full thickness flap is elevated again to the same
extent, the titanium framework is placed over the bony ridge and immobilized using
fixation screws, and the flap is sutured back with the vertical extensions emerging out
of the soft tissue.
• After a healing period of approximately one-and-half months, the periosteum gets
attached to the underlying bone firmly anchoring the framework. An impression of the
vertical extensions (abutments) is made and a fixed or removal type of prosthesis is
fabricated, and fixed or stabilized over the implant
44

45. (A) Subperiosteal implant (B) placed in the patient’s mouth
(C) supporting mandibular denture (D) post loading X-ray
45

46. ENDOSSEOUS IMPLANTS
• The “implants which are placed within the jaw bone
are called endosseous implants,” e.g. blade implants,
root form endosseous implants.
46

47. BLADE IMPLANTS
• Blade implants, which are very useful for narrow ridge
cases, are available prefabricated in the shape of
blades with an integrated abutment, which emerges
out of the soft tissue to support the prosthesis.
• The endosteal blade implant, was introduced
independently in 1967 by Leonard Linkow.
47

48. (A) Blade and root form implants in the facial view of the alveolar
ridge. (B) Blade implant in the cross-section view of the ridge.
48

49. Placement
• To place the blade implant, a full thickness flap is elevated to
expose the bony ridge and a thin sharp diamond
bur/disc/piezo saw is used to prepare a horizontal osteotomy
conforming to the size of selected implant.
• The implant is tapped into the prepared horizontal slot and
the flap is sutured back, leaving the abutment emerging out of
the soft tissue to hold the future removable or fixed type
prosthesis.
• The blade implants are restored 2 to 3 months after
placement
49

50. (A) To place a blade implant, flap is elevated to expose the ridge
crest and (B) a deep mid-crestal horizontal osteotomy is prepared
using piezo saw/rotary bur/disc etc. (C) The blade implant with
correct dimensions is inserted and tapped to fit into the prepared
osteotomy. (D) The flap is sutured back and (E) implant is loaded,
once it gets osseointegrated with the bone.
50

51. ENDOSSEOUS ROOT FORM IMPLANTS
• The two-stage, threaded, titanium root form implant was first
invented by Dr Branemark in 1978. These are now the most widely
used implants.
• The root form implant usually has two parts – one part, which is
inserted in the bone in the form root, is called the fixture and the
other part, which is called the abutment, is immediately or later
fixed to the fixture and emerges out of the soft tissue to hold the
prosthesis
51

52. TRANSOSTEAL IMPLANTS
• These implants are usually inserted in severely resorbed
mandibles where placing the endosseous implant may lead to
mandible fracture.
• They are mostly used to stabilize loose dentures. The posts
are inserted through the mandibular basal bone and
stabilized with a submandibular metal plate.
• This metal plate also prevents the mandible from getting
fractured.
• These implants are rarely used, as their insertion requires
major surgical intervention under general anaesthesia. 52

53. Diagrammatic presentation of transosteal implant
53

54. BASAL OSSEOINTEGRATED IMPLANTS (BOI)
• These implants are integrated to the high-density basal bone
or their basal discs are engaged bicortically, to avoid any
movement during function.
• To insert these implants, a lateral bone cutter is used to
prepare a lateral slot through the facial cortical plate and an
implant of exact size and shape is tapped from the lateral
access into the prepared slot.
• The flap is sutured around the implant abutment, which
emerges out of the soft tissue.
54

55. • These implants usually achieve high initial stability and thus
can be restored immediately or soon after implantation.
• These implants, because they have the advantages of
minimum inventories and immediate loading, have gained
high popularity and are being widely used by many implant
surgeons.
• These implants are very useful for cases with compromised
bone volume, limited bone height above the mandibular
canal, sinus pneumatization, etc.
• The only disadvantage with these implants is that their
placement needs the lateral approach 55

56. (A) Basal osseointegration implant
(B) being placed in the posterior mandible 56

57. CLASSIFICATION OF ENDOSSEOUS ROOT
FORM IMPLANTS
• Endosseous root form implants are the most widely used
implants. Several research projects and clinical trials have
been done and continue to be done, to develop an optimal
implant design.
• There are many parameters which differentiate one root form
implant from another, and dentists practicing or willing to
practice clinical implantology should know these features and
their benefits to successfully choose the correct implant
design.
• Root form implants can be classified as follows:
57

58. Root Form Implants Classified on The Basis of
Surface Design:
Non-threaded implants
• These implants do not have any threads along their body, and thus are
tapped into the prepared osteotomy slot. The non-threaded implant
offers the advantages of more surface area and more bone implant–
surface contact percentage (e.g. the Endopore implant).
• The limitations of these implants are that they require technique-
sensitive placement and only a conventional two-stage protocol can be
practised with these implants.
58

59. 59