3. Introduction
Endosseous dental implants & their
retained prostheses – great success over
the past few decades.
Branemark et al
Ultimate goal – satisfy patient’s desire to
replace missing teeth in an esthetic,
secure, functional & long lasting manner.
Series of decisions & proper evaluation
4. Basic considerations
Medical evaluation
Psychological evaluation
Periodontal &restorative status of retained
teeth
Assessment of available bone
5. Basic considerations
Medical evaluation
Contraindications No contraindications
No implants Psychological evaluation
Unrealistic Realistic expectations
expectations
Edentulous Partially
consider alternatives edentulous
periodontal
evaluation
Assessment of available bone
adequate not adequate
osseointegrated implants gingival & osseous
augmentation procedures
6. Evaluation of bone- clinical& radiological
Bone quantitity
Height & width, density
Bony undercuts
Anatomic features
Max. sinus,nasal cavity,
incisive foramen, canine
fossa.
Man. Canal, mental foramen
submandibular fossa, lingual
inclination
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11.
12. Bone quality (Lekholm & Zarb-1985)
Class1 –dense cortical bone
Class2 – dense cortical & trabecular
bone
Class3 – moderate cortical & trabecular
bone
Class4 – Thin cortical with poor
trabecular bone
Class 1 & 2 – good for implants
Class 3 & 4 – bone augmentation or
subperiosteal approach
13. Bone density
Computed tomography-axial images-
2,60,000 pixels- each pixel –CT no:
HOUNSFELD UNIT
Higher the CT unit the denser the tissue
D1 : > 1250 H units
D2 : 850 – 1250 units
D3 : 350 – 850 H units
D4 : 150 – 350 H units
D5 : < 150 H units
QCT, DPA, DXA, QUS Scintigraphy, Digital
radiography
14.
15. Periodontal status
Significant periodontal problems Healthy
not treatable Treatable problems
- inflammatory
- osseous
NO - mucogingival
Implants - occlusal
unsuccessful TREAT IMPLANTATION FEASIBLE
Consider available bone support
16. AVAILABLE BONE SUPPORT
Height > 10mm Ht < 10mm inadequate bone ht
Width < 6mm width 4 – 6mm or width
trajectory < 25’ trajectory>25’
endosseous bone subperiosteal
endosseous blade augmentation implants
cylinder implants
implants
* membrane assisted or hard
tissue grafts
* sinus elevation
* ridge expansion
* monocortical onlay grafts
17. Soft tissue management
Keratinised mucosa
esthetic
strong seal
resistant to masticatory forces & oral
hygiene procedures
18. Determine whether attached gingiva is needed
NO YES
STANDARD IMPLANT MODIFY SURGICAL IMPLANT
PROTOCOLS PROTOCOL
MAXILLARY ARCH MANDIBULAR ARCH
(ASSESS AMT OF MAST.MUCOSA)
MGJ to crest
NO AUGMENTATION PROCEDURE >2mm < 2mm
BEFORE IMPLANT SURGERY
FACIAL FREE
phase 1surgery GINGIVAL GRAFT
19. IMPLANT PLACEMENT PHASE 1 THERAPY
Determine distance from bone margin to MGJ
<3mm >3mm
Apically positioned flap in PHASE2 Gingivectomy in PHASE 2
Assess thickness of facial soft Assess thickness of facial soft
tissue tissue & width of osseous crest
thick thin thick thin
APF APF wide crest narrow REPOSITIONED FLAP
with CT ridge augm with ridge augmentation
GINGIVECTOMY REPOSITIONED FLAP
23. Patients for an osseointegrated implant
implants placed immediately in an extraction socket
Consider teeth with untreatable periodontal , endodontal lesion
flap surgery to expose site
determine the type of defect & site present
Inadequate site stable implant can be placed
remove implant assess the type of defect
fenestration intraalveolar dehiscence very narrow
defect ridge
24. FENESTRATION
Consider number of threads exposed
1 or 2 threads exposed more than 3 threads exposed
Leave implant as is & close GBA
INTRA ALVEOLAR DEFECT
consider number of walls missing
narrow, 1 to 3mm deep wide, >3mm deep
1 to 3 threads exposed more than 3 threads exposed
leave implant as is & close GBA
25. DEHISCENCE DEFECT
consider number of walls missing
1 or 2 walls missing more than 2 walls missing
More than 3mm of implant
exposed
GBA REMOVE IMPLANT
VERY NARROW RIDGE
GBA
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29. SINGLE IMPLANTS
EVALUATION OF ADJACENT TEETH
crown to- root ratio
root morphology
tooth mobility & sulcus depths
Evaluation of edentulous space
length 10mm – min. reqd.
13mm – better
>13mm – best
Bone quality
Evaluation of implant loading
30.
31. Multiple implants
Evaluation of remaining teeth
tooth supported FPD abutments
teeth opposing implants
teeth adjacent to implants
teeth located in the same or opposing
arch
Functional & parafunctional incisal loading
horizontal overlap < 1mm
vertical overlap
0-2mm – minimal loading force
3-5mm – moderate loading force
>=6mm – extensive loading force
Functional occlusal loading
32. Minimal loading force -light centric
contacts & absence of incline contact
Moderate loading force – solid centric
contacts & presence of incline contact on
shallow morphology
Extensive loading force _ heavy centric
contacts & presence of incline contact on
steep occlusal morphology
33. Number of implants for edentulous spaces
mesiodistal dimension
implant length & diameter
bone quality
implant loading
Unfavorable conditions for implants
short length <10mm
poor bone quality
extensive loading
Neutral conditions
average length 10 – 13mm
average bone quality
moderate loading
Favorable conditons
long implants 15mm or more
good quality bone
minimal loading
34. Patients with multiple implants or implanys as abutments
evaluate remaining teeth
assess periodontal status
Healthy or predictably treatable severely compromised
Determine functional & parafunctional extract teeth & evaluate
Incisal & occlusal loading edentulous spaces
Adequate abutments for inadequate tooth abutments
Edentulous spaces
Tooth supported FPD determine no: of implants for edentulous spaces
35. NO: OF IMPLANTS
Favorable conditions neutral conditions unfavorable conditions
2 implant abutments one implant for each two implant for each missing
forimplant missing tooth molar. One implant
supported adjacent implants for each additional
3 or 4 unit splinted or as missing tooth
FPD individual units all adjacent implants
splinted together
36. Loading
no: of implants, implant length,bone
quality, angulation of implant, occlusal
force, cuspal inclination.
Linear & non linear arrangement
axial & nonaxial forces
