Dental implants. surgical stages

1. Basic Surgical Techniques for
Endosseous Implant Placement
Bilozetskyi Ivan

2.  Dental implant is
an artificial titanium
fixture
which is placed
surgically into the
jaw bone to
substitute for a missing
tooth and its root(s).
WHAT IS A DENTAL IMPLANT?

3. In 1952, Professor Per-Ingvar Branemark,
a Swedish surgeon, while conducting research
into the healing patterns of bone tissue, accidentally
discovered that when pure titanium comes into
direct contact with the living bone tissue, the two
literally grow together to form a permanent
biological adhesion. He named this phenomenon
"osseointegration".
History of Dental Implants

4. All current implant
designs are
modifications of this
initial design
First Implant Design by Branemark

5. STEP 1: INITIAL SURGERY
STEP 2: OSSEOINTEGRATION PERIOD
STEP 3: ABUTMENT CONNECTION
STEP 4: FINAL PROSTHETIC
RESTORATION
Surgical Procedure

6. Fibro-osseous integration
• Fibroosseous integration
– “tissue to implant contact with dense collagenous
tissue between the implant and bone”
• Seen in earlier implant systems.
• Initially good success rates but extremely
poor long term success.
• Considered a “failure” by todays standards

8. Osseointegration
• Success Rates >90%
• Histologic definition
– “direct connection between living bone and load-
bearing endosseous implants at the light
microscopic level.”
• 4 factors that influence:
Biocompatible material
Implant adapted to prepared site
Atraumatic surgery
Undisturbed healing phase

9. Soft-tissue to implant interface
• Successful implants have an
– Unbroken, perimucosal seal between the soft
tissue and the implant abutment surface.
• Connect similarly to natural teeth-some
differences.
– Epithelium attaches to surface of titanium much
like a natural tooth through a basal lamina and the
formation of hemidesmosomes.

10. Soft-tissue to implant interface
• Connection differs at the connective tissue
level.
• Natural tooth Sharpies fibers extent from the
bundle bone of the lamina dura and insert into
the cementum of the tooth root surface
• Implant: No Cementum or Fiber insertion.
Hence the Epithelial surface attachment is
IMPORTANT

12. Subperiosteal

13. Transmandibular Implant

16. Blade Implant

17. Endosteal Implants

18. The “Parts”
• Implant body-fixture
• Abutment (gingival/temporary healing vs.
final)
• Prosthetics

19. Clinical Components

20. abutment

21. Team Approach
• A surgical – prosthodontic consultation is
done prior to implant placement to address:
– soft-tissue management
– surgical sequence
– healing time
– need for ridge and soft-tissue augmentation

22. Clinical Assessment
• Assess the CC and Expectations
• Review all restorative options:
– Risks and Benefits
• Select option that meets functional and
esthetic requirements

23. Patient Evaluation
• Medical history
– vascular disease
– immunodeficiency
– diabetes mellitus
– tobacco use
– bisphosphonate use

24. History of Implant Site
• Factors regarding loss of tooth being replaced
– When?
– How?
– Why?
• Factors that may affect hard and soft tissues:
– Traumatic injuries
– Failed endodontic procedures
– Periodontal disease
• Clinical exam may identify ridge deficiencies

25. Surgical Phase- Treatment Planning
• Evaluation of Implant Site
• Radiographic Evaluation
• Bone Height, Bone Width and Anatomic
considerations

26. Basic Principles
• Soft/ hard tissue graft bed
• Existing occlusion/ dentition
• Simultaneous vs. delayed reconstruction

27. Smile Line
• One of the most influencing factors of any
prosthodontic restoration
• If no gingival shows then the soft tissue
quality, quantity and contours are less
important
• Patient counseling on treatment
expectations is critical

28. Anatomic Considerations
• Ridge relationship
• Attached tissue
• Interarch clearance
• Inferior alveolar nerve
• Maxillary sinus
• Floor of nose

29. Radiological/Imaging Studies
• Periapical radiographs
• Panoramic radiograph
• Site specific tomograms
• CAT scan (Denta-scan, cone beam CT)

30. Width of Space and Diameter of Implant
Attention must be paid to both the coronal and
interradicular spaces

32. A case against routine CT
• Expense
• Time consuming process
• Use of radiographic template/proper fit
requires DDS present
• Contemporary panoramic units have
tomographic capabilities
• Usually adds no additional data over
standard database

35. Image Distortion

36. Anatomic Limitations
Buccal Plate 0.5mm
Lingual Plate 1.0 mm
Maxillary Sinus 1.0 mm
Nasal Cavity 1.0mm
Incisive canal Avoid
Interimplant distance 1-1.5mm
Inferior alveolar canal 2.0mm
Mental nerve 5mm from foramen
Inferior border 1 mm
Adjacent to natural tooth 0.5mm

37. Dental Implant Surgery Phase I
• Aseptic technique
• Minimal heat generation
– slow sharp drills
– internal irrigation?
– external cooling

38. Dental Implant Surgery Phase I
• Adequate time for integration
• Adequate recipient site
– soft tissue
– bone
• Kind & Gentle technique

48. 1. Chlorhexidine
2. Analgesics
+/- antibiotics
Disposition

49. Implant placement 3 months after menton bone
grafting

52. Exposure of Implant during
Placement

55. Summer’s Osteotomes

56. Limitations to Implant placement in the
Maxilla
• Ridge width
• Ridge height
• Bone quality

57. Surgical Solutions to Anatomical
Limitations
Onlay Bone Graft Sinus Lift

58. Summers, RB. A New concept in Maxillary
Implant Surgery: The Osteotome technique.
Compendium. 15(2): 152, 154-6
• Ridge expansion technique
– 3-4 mm of crestal alveolar width
required
• Sinus floor elevation technique
– 8-9 mm of alveolar bone height
required in order to place a 13 mm
implant
(4-5 mm sinus floor elevation)

60. Introduction
Ridge expansion technique
• 1.6 mm pilot hole
• Summers osteotome # 1-4
– sequenced tapered osteotomes.
– ridge expansion (displacement) versus
bone removal.
• Final drill coincident with the final
implant size (sometimes not
necessary)

62. Introduction
Sinus floor elevation technique
• 1.6 mm pilot hole
• Summers osteotome # 1-4
– Sinus floor microfractured superiorly
– Sinus floor can be elevated 4-5 mm
– May backfill with bone allograft/alloplast
• Final drill coincident with final
implant size

64. Surgical Technique

66. A. Rake, K. Andreasen, S. Rake, J. Swift A Retrospective
Analysis of Osteointegration in the Maxilla Utilizing an
Osteotome Technique versus a Sequential Drilling
Technique, 1999 AAOMS Abstract
• 155 maxillary implants in 84 patients restored
for at least 6 months
– 57 were placed utilizing the osteotome technique
– 98 were placed utilizing the drilling technique
• One implant failed of the 98 in the drill group
• None of the implants had failed of the 57 in the
osteotome group

67. Stage II Surgery Preoperative
Considerations
• 3-6 months after stage I

68. Stage II Surgery Preoperative
Considerations
• Done under local anesthesia
• Pre-op medications
– Chlorhexidine rinse

71. Placement of
healing abutment

78. • The failing implant is very difficult to treat
• Traumatic surgical manipulation with
initial instability of implant increases risk
of failure
• Implant success is only as good as the
prosthodontic reconstruction
conclusions