seminar in oral surgery about introduction to dental implants

1. Introduction to dental implants
Prepared by
Ibrahim Meneim Hussien

2. INTRODUCTION
The development of endosseous osseointegrated dental implants
has been very rapid over the last two decades. There are now
many implant systems available that provide the clinician with
* a high degree of predictability in the attainment of osseointegration
* versatile surgical and prosthodontic protocols
*design features that facilitate ease of treatment and aesthetics
* a low complication rate and ease of maintenance
*published papers to support the manufacturer’s claims
* a reputable company with good customer support

3. Dental implantation
• The loss of one or more teeth is a serious and aesthetic medical problem
which results in degradation of the person life quality.
• Dental implantation is a modern and efficient way to solve this problem.
With its help it is possible to correct the defects of dentition of any length ,
to provide reliable prosthesis fixation and to avoid bone atrophy. Dental
implants are the latest & greatest in dental technology that allows dentist
to replace missing teeth permanently.
• You may know that implants can replace teeth & are used in complete
smile reconstructions & makeovers. But you may also not be sure exactly
what dental implants are, & how they work.
• With the quickly-advancing technology of dental implants, we can finally
offer a restorative dentistry option that replaces your missing teeth both
visually & functionally.

4. Dental implants actually consist of two parts, just like your natural teeth.
The implant itself acts as an artificial tooth root & is secured in the bone of your jaw
just like a real root. Implants are made of a special kind of bio-safe titanium. Both
this special metal & the screw-like shape of the implant’s lower portion are
designed so that bone will grow around it, keeping it tightly in place.
The second part of the dental implant is the crown. This is an artificial tooth that is
made of porcelain & is custom designed by a dental technician to match the color,
size & shape of your natural teeth. It is attached to the metal implant using a
permanent dental adhesive.

5. Is tooth replacement necessary?
The loss or absence of a tooth should always prompt some consideration as to the
appropriateness of replacing it. There are many situations where it is not necessary
to replace every missing tooth in the dental arch. A decision to do so will be based
on the impact of the missing tooth or teeth on the patient's lifestyle, as determined
by the patient, and a professional assessment as to the potential harm that may
arise from failure to replace the unit. Patients tend to complain most about teeth
missing from the front of the mouth, which has a negative impact on their
appearance and speech, and where sufficient posterior teeth have been lost to
make mastication difficult. A professional decision to replace missing teeth may also
be dependent upon the potential for drifting and overeruption of the remaining
teeth, although this does not inevitably follow tooth loss . Of considerable
importance also are the techniques that are potentially available to replace the
missing tooth, and in many cases the tissues that previously supported it. All will
have implications for the patient in terms of morbidity and cost, which may make
the replacement ill matched to the patient's best interests.

6. Does tooth replacement need to be with an implant?
Where it has been decided to replace missing teeth, the use of an implant-
stabilized prosthesis is merely one of a range of techniques that may be
potentially available to the dentist. All will carry various benefits and
disadvantages, and an evidence-based decision should be taken where possible
as the most appropriate technique in a particular situation. In some cases
implant treatment will be feasible and appropriate; however, there are many
situations where this is not the case and a patient is best served by other forms
of treatment.

7. Systemic factors having known links with implant failure
Tobacco smoking. This has been shown to increase the risk of implant failure.
Systemic factors having possible association with implant failure
• Active chemotherapy.
• Disphosphonate therapy.
• Ectodermal dysplasia.
• Erosive lichen planus.
• Type 2 (late-onset) diabetes: This is especially the case where this is not well controlled.
• Treatment by an operator with limited surgical experience.
Local factors having strong associations with implant failure
• The placement of implants in severely resorbed maxillae.
• A history of irradiation of the implant site.
• The use of implants of a press-fit cylindrical design.
Matters less strongly associated with a risk of implant failure
• The placement of implants in infected extraction sites.
• The use of small numbers of implants in the posterior maxillae.
• The use of short as opposed to long implants

8. PATIENT FACTORS
There are few contraindications to implant treatment. Following are the
main potential problem areas to consider:
* Age
* Untreated dental disease
* Severe mucosal lesions
*Tobacco smoking, alcohol and drug abuse
*Poor bone quality
* Previous radiotherapy to the jaws
*Poorly controlled systemic disease such as diabetes
*Bleeding disorders

9. Dental implant components
IMPLANT BODY: Often referred to as an implant
COVER SCREW : Prevents bone ingress in the implant head
TRANSMUCOSAL ABUTMENT (TMA):Links the implant body to the mouth. May be
pre-manufactured or custom formed
HEALING ABUTMENT: Placed temporarily on the implant body to maintain patency
of the mucosal penetration
TEMPORARY COMPONENTS :Pre-manufactured components used to make
temporary crowns and bridges for fitting on dental implants and abutments
IMPRESSION COPING :Used to transfer the location of the implant body or abutment
to a dental cast
LABORATORY ANALOGUE: Abase metal replica of the implant body, or a pre-
manufactured abutment
GOLD CYLINDER : Pre-manufactured to fit an abutment and form part of a prosthesis
HEALING CAPS : Temporary covers for abutments

11. Dental implant body
This term describes the component placed in the bone, which is
sometimes also referred to as an implant, fixture or implant
fixture. Occasionally the term is used colloquially to describe
both the endosseous component and those parts placed
immediately on top. The preferred term for the endosseous
component is 'dental implant body', or 'implant body.The
majority of dental implants are designed to be placed into holes
drilled in the bone and are thus axisymmetric. Many are screw
shaped, since this aids in primary stability, and are inserted into
tapped holes.
Where bone has a low density this may result in poor stability
and thus some designs incorporate self tapping features to
overcome this problem. Others are made with a tapering design,
which creates a wedging effect as the implant body is seated. In
addition to screw threads, other surface features may be
included with the intention of enhancing OI. Typical of these are
macro surface irregularities, and porous metallic and ceramic
coatings, typically of hydroxyapatite. These features usually also
enhance retention, which is important since an osseointegrated
smooth titanium surface has a low shear strength.

12. Cover screw
This is placed at the time of first-stage
surgery, and removed when locating
the abutments. Where the implant
body is not internally threaded the
description 'screw' is inappropriate.
Although the term 'dental implant
obturator' has been proposed the name
'cover screw' is in wide use.

13. Transmucosal abutment (TMA)
This is used to link the implant body to the prosthesis , and may also be
referred to as an implant abutment. The proposed standard term is 'dental
implant connecting component'. These parts have evolved from a simple
cylindrical device into a family of components basically of four types:
cylindrical, shouldered, angled and customizable. They are usually, but not
exclusively, are provided in a range of lengths and, in the case of the
shouldered design, shoulder heights, The cylindrical designs are employed
where the mucosal aspect of the prosthesis is to be placed some distance
above the oral mucosa to aid cleaning, the so-called 'oil rig' design. While this
gap can prove troublesome to some patients, it is not normally evident where
the adjacent lip is long, and can undoubtedly aid cleaning.

14. Healing abutment
This is a temporary implant-
connecting part placed on the
implant body to create a channel
through the mucosa while the
adjacent soft tissues heal.

15. Impression coping
This is also described as a dental
implant impression cap, and is used
to transfer the position of the implant
body or the abutment to the working
cast.

16. Gold cylinder
This pre-manufactured component is used to link the
superstructure to the abutment, and is usually screw
retained. It can be provided in a range of shapes depending
on the abutment design and may be intended for soldering
to a gold bar for use with an overdenture, incorporation in a
cast superstructure as the basis of a fixed bridge or as part of
a single crown. Where it forms the basis of a single crown it
is normal for it to incorporate an anti-rotation feature, such
as an internal hexagon, a feature that may be present for
other applications.

17. Healing caps
Most manufacturers provide
temporary polymeric covers for
their abutments to prevent
damage and fouling of the screw
retainer when the patient has to
be without the superstructure
during its fabrication or repair.

18. Implant Joints
There are two methods of
joining implant superstructures
to the abutments: screwed and
cemented joints. The latter use
standard dental cements,
sometimes reformulated by the
manufacturer for this
application.

19. Screwed joints
A screwed joint functions by virtue of its components
being held tightly together by the tension in the screw,
acting after the fashion of a spring.
ADVANTAGES?
• Retrievability . Easy to remove
• Control of gap. This can be precise
• Predictable failure. Can be designed as a weak point in the system
DISADVANTAGES?
• Mechanical failure. Can be problematical
• Access holes. Necessary for screw placement
• Contamination. Can permit ingress of material and
microorganisms from the mouth
• Angulation problems. May be very difficult to manage where long
axis of crown diverges markedly from that of the implant body

20. Cemented joint
ADVANTAGES?
• Simplicity. A familiar and relatively simple technology
• Passivity. A passive fit is theoretically possible
• Angulation. Less of a problem than with screws, no access hole
DISADVANTAGES?
• Retrievability . Difficult or impossible to remove without
damaging superstructure
• Cement excess. Difficult to avoid, detect and remove

21. Type of dental implants
• Endosteal implant
• Supberiosteal implants
• Transosteal implants
• Endosteal implants :the gum opened up ,then a hole is drilled within the bone .
Titanium screw and cylinder are then inserted within the jaw bone
• Once the bone has healed , the teeth can be secured in place.
• Subperiosteally implants (less common) :screw placed on the top of the bone but
under the gum line , this method use only for patients who have minimal bone height
& are unable un willing to wear dentures
• Transosteal implants :also called stable bone implant ,transmandibular implant
.penetrate both cortical plate and passes through the entire thickness of the alveolar
bone
• Use restricted to anterior area of mandible

22. dental implantation method
• Early loading (e.g. at 6 weeks)
• There is good research evidence that high initial loads on an implant
immediately following placement result in the formation of a fibrous capsule
rather than OI. Nevertheless there is evidence from clinical studies that where
the implant has good primary stability, early loading does not apparently
preclude OI, below an ill-defined threshold.

23. Late loading (for 3-6 months)
It has been shown that excessive mechanical loads on an osseointegrated implant
can result in breakdown of the interface with resultant implant failure, and it is
generally considered that overload is therefore to be avoided. This could arise as a
result of bruxism, in patients who habitually use high occlusal forces, and as a
result of superstructure designs in which the use of excessive cantilevering causes
high forces on the implants. The research evidence for a link between occlusal
loads and loss of OI is, however, not extensive, and there are currently no clinical
guidelines as to its determination in a particular patient other than by general
principles. Since bone is a strain-sensitive material, the modelling and remodelling
of which is influenced by deformation, it is thought that there is probably a range
of strains that are associated with bone formation and could thus be
of therapeutic value.

24. Immediate Loading ( directly after tooth extraction)
It has also been demonstrated that immediate loading is compatible with
subsequent successful osseointegration, provided the bone quality is good
and the functional forces can be adequately controlled. In studies on single
tooth restorations, the crowns are usually kept out of contact in intercuspal
and lateral excursions, thereby almost eliminating functional loading until a
definitive crown is provided. In contrast, fixed bridgework allows connection
of multiple implants providing good splinting and stabilization and therefore
has been tested in immediate loading protocols with good success. However,
the clinician should have a good reason to adopt the early/ immediate loading
protocols particularly as they are likely to be less predictable.

25. Local factor should be consider when completing possible implant
treatment
ACCESS : Room to insert the implants?
PROSTHETIC SPACE : Room to place a restoration?
DYNAMIC SPACE TO RESTORE THE IMPLANT: Do occlusal interferences preclude superstructure placement?
SIZE OF SPACES : How many implants?
BONE VOLUME : Will it house a suitable implant?
BONE CONTOUR : Will the implant penetrate a concavity?
BONE ORIENTATION : Can the implant be oriented correctly?
PROGNOSIS OF REMAINING TEETH? : Restore the mouth in its entirety
STATUS OF EXISTING PROSTHESES : Could they be improved upon? With implants?
Oral hygiene : implant treatment should only be carried out in patients with good oral

26. Step of dental implantation (late loading)
Step 1: consultation
• Before dental implants installation you should consult the doctor and
make sure that the implantation is the best solution for you
• Diagnostics : radiography and CT or CBCT scan.

27. STEP2: REHAPITATION WAY AND IMPLANT SYSTEM SELECTION
• The doctor select the rehabilitation system depending on the medical
case. The construction can be non fixed , cementable or screwed.
• To select right dental implant system one should pay attention to the
following moments :
• Form and modern implant surface
• Usability
• Quality guarantee

28. Step 3: IMPLANTATION
• Implant instillation is practically painless procedure almost the same as
other dental procedure . It usually lasts no longer than 30 minute.
• The implant survival period lasts from 3 to 6 months depending on the
medical case. Dental flipper on the dental implant solves the aesthetic
problem as it can be installed at once.

29. Step 4 : GINGIVAL TISSUE FORMATION
• Healing cap is installed after implant
survival for the period of 7-10 day and it’s
the pretreatment for the further
prosthetics.

30. Step 5 : IMPRESSION TAKING
• Impression taking occurs in 10 days
after healing cup installation . The
procedure in general takes 15-20
minutes depending on the medical
case . Then the impression are sent
to the dental laboratory.

31. Step 6 : CONSTUCTION TRAY-IN
• The doctor tries in the construction that was made in the dental laboratory
and correct it if necessary

32. Step 7 : construction fixation
• The doctor fixes the construction and consult the patient . Congratulation
on your new smile

33. Step 8 : planned examination
• Do not forget about planned
medical re-examination exactly in 3
months.

34. References
• Implants in Clinical Dentistry
Second Edition
Richard M. Palmer, PhD, BDS, FDS RCS (Eng), FDS RCS (Ed)
Professor of Implant Dentistry and Periodontology, King’s College London Dental Institute,London SE1 9RT, U.K.
Leslie C. Howe, BDS, FDS RCS (Eng)
Head of Conservative Dentistry, King’s College London Dental Institute, London SE1 9RT, U.K.
Paul J. Palmer, BDS, MSc, MRD RCS (Eng)
Consultant in Periodontology, Guy’s and St Thomas’ NHS Foundation Trust, London, U.K.
With Contributions From
Kalpesh Bavisha, BDS, MSc, FDS RCPS (Glasg)
Consultant in Restorative Dentistry, Guy’s and St Thomas’ NHS Foundation Trust, London, U.K.
Mahmood Suleiman, PhD, BDS, MSc, MFGDP
Hon Specialist Clinical Teacher Implant Dentistry, Guy’s and St Thomas’ NHS Foundation Trust;
Associate Specialist Maxillofacial Surgery, Ashford and St. Peter’s Hospitals, London, U.K.
This edition published in 2012 by Informa Healthcare, 37–41 Mortimer Street, London W1T 3JH, UK.
• Implants in Clinical Dentistry
Richard M Palmer PhD, BDS, FDS, RCS (Eng), FDS RCS (Ed)
Professor of Implant Dentistry and Periodontology,
Guy’s, Kings and St Thomas’ Hospitals Medical and Dental Schools,
London, SE1 9RT, UK
Brian J Smith BDS, MSc, FDS RCS (Eng)
Consultant in Restorative Dentistry, Unit of Restorative Dentistry,
Guy’s and St Thomas’ Hospitals Trust, London, SE1 9RT, UK
Leslie C Howe BDS, FDS RCS (Eng)
Consultant in Restorative Dentistry, Guy’s and St Thomas’ Hospitals Trusts
and Specialist in Restorative Dentistry and Prosthodontics,
21 Wimpole Street, London W1M 7AD, UK
Paul J Palmer BDS, MSc, MRD RCS (Eng)
Specialist in Periodontics, 21 Wimpole Street, London W1M 7AD and
Postgraduate Tutor in Implant Surgery, Guy’s, Kings and St Thomas’
Hospitals Medical and Dental Schools,
London, SE1 9RT, UK
this edition is published in the Tylor & francis e-library,2002.
• INTRODUCIND Dental Implants
johnA.Hobkirk
Roger M.Watson
Lioyd J.J.Searson
Forward by George A. Zarb