Dental Implant

1. DENTAL IMPLANTDENTAL IMPLANT
Dr. Saleh BakryDr. Saleh Bakry
Assistant Professor of Oral and Maxillofacial SurgeryAssistant Professor of Oral and Maxillofacial Surgery

2. OSSEOINTEGRATION
• Osseointegration refers to the immediate structural, biological, and functional
connection between metal implants and healthy bone, without soft, non-
calcified connective tissue intervening.
THE AIMS OF PLACING OSSEOINTEGRATED DENTAL
IMPLANTS ARE
• Replacement of dentition and supporting tissues to restore function and
appearance.
• Alveolar bone preservation.

3. INDICATIONS
• Severe denture intolerance due to any of the following reasons:
Severe gagging.
Severe ridge resorption with unacceptable stability or pain.
Psychological.
• Bone preservation and prevention of disuse atrophy after tooth loss.
• Developmental anomalies.
Hypodontia.
cleft palate.
• Trauma resulting in loss of teeth and supporting tissues.
• Complete unilateral loss of teeth in one jaw.
• Orthodontic anchorage.
• Restoration of dental esthetics.

4. CONTRAINDICATIONS
• Uncontrolled diabetes or heart disease.
• Taking intravenous or oral bisphonates for certain forms of breast cancer.
• Radiation therapy to the head and neck.
• Heavy smoking is a risk.
• Untreated intraoral pathology or malignancy.
• Untreated periodontal disease.
• Uncontrolled psychiatric disorders.
• Uncontrolled drug or alcohol use (abuse).
• Recent myocardial infarction (MI) or cerebrovascular accident (CVA) or valvular
prosthesis surgery.
• Inability to maintain high levels of plaque control
• Immunosuppression-eg following organ transplants

5. INSTRUMENTS
The instruments used for the placement of screw-type implants are the following:
Surgical micromotor (Piezo dispenser motor)
appropriate for placement of implants
Titanium and stainless steel instruments,
which are separated and placed in a special
tray during the surgical procedure (the
implant not include in the kit).

6. SURGICAL PROCEDURE

7. I. CREATION OF FLAP
Mandible
•In the edentulous mandible, and after administration of an inferior alveolar nerve
block, an incision is made using a no. 15 scalpel blade.
•The Mucoperiosteum is reflected until the alveolar crest is exposed.

8. I. CREATION OF FLAP
Maxilla
•In an edentulous maxilla, after administration of bilateral nerve blocks of the
anterior superior alveolar nerve, nasopalatine nerve, well as infiltration anethesia
labially or buccally and palatally, a straight incision is made at the height of the
alveolar crest.
•The Mucoperiosteum is reflected until the alveolar crest is exposed.

9. II. PREPARATION OF IMPLANT RECIPIENT SITE
BY DRILLING AT HIGH SPEED
• The first bur used to prepare the bone is the round guide bur.
• This bur is used at high speed, approximately 2000 rpm.

10. II. PREPARATION OF IMPLANT RECIPIENT SITE
BY DRILLING AT HIGH SPEED
• Drilling of the bone is performed with constant irrigation of saline solution, while the bur
must move in an up-down direction.
• A spiral bur with a diameter of 2mm is then used to prepare the implant recipient sites.

11. II. PREPARATION OF IMPLANT RECIPIENT SITE
BY DRILLING AT HIGH SPEED
• Paralleling pin is then placed in the recipient site, serving as a guide for the
gradual preparation of the rest of the recipient sites.

12. II. PREPARATION OF IMPLANT RECIPIENT SITE
BY DRILLING AT HIGH SPEED
• The next stage of widening the implant recipient sites is achieved using a longer
twist bur, also with a diameter of 3 mm.
• A marginal countersink with a conical shape can often be used to prepare the shelf
for installation of the implant.

13. III. PREPARATION OF THREADS IN IMPLANT RECIPIENT
SITE BY DRILLING AT LOW SPEED (REQUIRED BY ONLY A
FEW SYSTEMS).
• This stage involves the preparation of threads inside the recipient site by drilling
at low speed (15-20 rpm).

14. IV. INSTALLATION OF IMPLANT AND PLACEMENT OF
COVER SCREW.
• In this step, the implant is adapted to the receiver of the implant mount, which has
been placed in the low-speed contra-angle hand piece and is transferred to the
implant recipient site.

15. IV. INSTALLATION OF IMPLANT AND PLACEMENT OF
COVER SCREW.
• The implant is screwed into the bone without pressure, until the engine of the
handpiece stops on its own.
• Afterwards, a cylinder wrench is used to screw the implant manually as far as the
deepest part of the recipient site.
• The implant mount is removed by using a screwdriver.
• In the final step, a cover screw is placed, which covers the horizontal surface of each
implant, thus preventing intervention or proliferation of the mucosal tissues inside
the implant.
• The flap is repositioned and sutured with interrupted sutures.

16. IV. INSTALLATION OF IMPLANT AND PLACEMENT OF
COVER SCREW.

17. IV. INSTALLATION OF IMPLANT AND PLACEMENT OF
COVER SCREW.
• As for the surgical procedure, antibiotics are administered prophylactically
(preoperatively), as well as analgesics for management of postoperative pain.
• The sutures are removed 7 days after the operation.
• Usually a healing time of 8 weeks is recommended by the manufacturers.

18. UNCOVERING AN IMPLANT
1. THE TISSUE PUNCH.
•This is easiest when the implant itself may be palpated, or if there is sufficient
keratinized tissue.
•Its advantages include minimal trauma and very little discomfort for the
patient.

19. UNCOVERING AN IMPLANT
2. THE FULL-THICKNESS FLAP TECHNIQUE.
3. THE CRESTAL INCISION.
•Require sufficient attached tissue.
•Its advantage is direct visualization of the bone area and not having to rely on
tactile sense alone.
4. THE PARTIAL-THICKNESS FLAP GINGIVECTOMY.
•Used If there is insufficient keratinized tissue.
•This method is more painful and requires longer healing time.

20. • Any hard or soft tissues, which may intervene between the implant and the
cover screw otherwise the precise and complete adaptation and seating of the
abutment on the implant will be prevented.

21. • A healing abutment is used for 7-14 days before the impression can be taken.
• Then 15-20 days after placement of the abutments, the patient is ready to
begin the procedure for a fixed or mobile prosthetic restoration.

22. BASIC PREREQUISITES IN IMPLANT SURGERY
FOR A SUCCESSFULL OSSEOINTEGRATION
• A sterile technique avoiding contamination of the implant surface.
• Avoiding damage to the bone by thermal injury during the drilling process.
• Carefully preparing the bone site so that the implant is stable at placement
(initial stability).

23. COMPLICATIONS
• Damage to adjacent anatomic structures, in the case of perforation of the
maxillary sinus, nasal cavity, and mandibular canal by the implant.
• Mucosal perforation Ô mishandling during flap retraction or by damage of the
soft tissues due to a temporary prosthetic restoration
• Failure of osseointegration, Due to:
 Premature loading of implants during the healing period.
 Bone damage because of the surgical procedure.
 Improper design of the prosthetic restoration or ill-fitting prosthetic work.
 Poor judgment of the quality of bone at the implant recipient site.
• Gingivitis, gingival hyperplasia, or the appearance of a fistula Exposure of
implant threads.

24. NATURAL TOOTH VERSUS IMPLANT SUPPORT
SYSTEMS
TOOTH IMPLANT
Periodontal membrane PDL:
•Shock absorber.
•Distribution of force around the tooth.
•Tooth mobility can be related to force.
•Mobility dissipates lateral force).
•Radiographic changes related to force (reversible).
Direct bone/implant:
•Higher impact force
•Force primarily to crest
•Implant is always rigid (mobility is failure).
•Lateral force increases strain to bone.
• Radiographic changes at crest (bone loss
not reversible)

25. NATURAL TOOTH VERSUS IMPLANT SUPPORT
SYSTEMS
TOOTH IMPLANT
Occlusal material: enamel Ô early signs of force as
enamel wear, stress lines, pits
Occlusal material porcelain (metal crown)
no early signs of force
Connection Ô PDL Connection Ô Functional ankyloses
Impact force Ô Decreased Impact force Ô Increased
Mobility Ô Variable: anterior teeth more than
posterior
Mobility Ô None
Cross section Ô Not round Cross section Ô Round

26. NATURAL TOOTH VERSUS IMPLANT SUPPORT
SYSTEMS
TOOTH IMPLANT
Orthodontic movement Ô Yes Orthodontic movement Ô No
Radiographic changes Ô PDL and cortical bone
thickening
Radiographic changes Ô Crestal bone loss
Tactile sensitivity Ô High Tactile sensitivity Ô Low
Occlusal awareness (proprioception) High detection
of premature contacts
Occlusal awareness (proprioception)
Ô low.

27. TYPES OF DENTAL IMPLANTS
1. ENDODONTIC STABILIZER

28. TYPES OF DENTAL IMPLANTS
2. MUCOSAL INSERTS (BUTTON IMPLANTS)

29. TYPES OF DENTAL IMPLANTS
3. SUBPERIOSTEAL IMPLANTS

30. TYPES OF DENTAL IMPLANTS
4. ENDOSTEAL IMPLANTS
A. Transmandibular dental implants (staple bone plates)

31. TYPES OF DENTAL IMPLANTS
4. ENDOSTEAL IMPLANTS
B. Ramus blade and ramus frame endosteal implants:

32. TYPES OF DENTAL IMPLANTS
4. ENDOSTEAL IMPLANTS
C. Blade form implants

33. TYPES OF DENTAL IMPLANTS
4. ENDOSTEAL IMPLANTS
D. Root form implants (cylindrical):

34. TYPES OF DENTAL IMPLANTS
4. ENDOSTEAL IMPLANTS
D. Root form implants (cylindrical):
• Are the most commonly used and are shaped in the form of a tooth root that may be
cylindrical or tapered.
• Root form implants require at least 10 mm vertical bone height, 6 mm buccolingual
width, and 8 mm mesiodistally to avoid undesirable complications.
• There should be at least 1.5 mm of bone surrounding the circumference of the implant
and the distance between the centers of two adjacent implants should not be less than 7
mm.

35. CLASSIFICATION OF ROOT FORM IMPLANTS
1. DESIGN
•Cylindrical.
•Tapered screw.
•Hybrid.

36. CLASSIFICATION OF ROOT FORM IMPLANTS
2. MATERIAL
•Pure titanium (osteoinductive and osteoconductive).
•Titanium alloy.
3. SURFACE TREATMENT AND SURFACE CHARACTERISTICS
•Titanium oxide surface.
•Sandblasted surface.
•Plasma sprayed surface.
•Hydroxyapetite coating.

37. CLASSIFICATION OF ROOT FORM IMPLANTS
4. MANNER OF INSERTION
•Press fit: the implant site is drilled to a slightly smaller diameter than the
actual implant. Friction provides primary stability.
•Self-tapping: the implant is threaded whereby the implant threads are used to
tap the site during its insertion into bone. The screw form provides initial
stability.
•Pretapped: are also threaded implants but their sites are tapped using a bone
tapping instrument prior to implant insertion.

38. CLASSIFICATION OF ROOT FORM IMPLANTS
5. TIME OF LOADING
•Immediate loading: Early loading can lead to interfacial formation of fibrous
tissue instead of bone.
•Delayed loading: A healing time without loading of 3-4 months in the maxilla
and 4-6 months in the mandible allows for better osseointegration
6. BIOLOGIC RESPONSE
•Fibrointegration.
•Osseintegration.
•Biointegration (with a hydroxyapatite coated implants).
•Ligament integration.

39. CLASSIFICATION OF ROOT FORM IMPLANTS
7. SURGICAL STAGES OF PLACEMENT
•One stage design: The body of the implant is inserted into the bone whereas
its abutment portion penetrates the oral mucosa.
•Two stage design: The implant body is completely embedded in bone in the
first stage surgery until it is totally osseointegrated before it is the exposed and
an abutment is mounted and screwed in place.

40. CLASSIFICATION OF ROOT FORM IMPLANTS
8. TIME OF INSTALLATION
•Immediate implantation: An implant is placed into a fresh extraction socket. It
should extend 1-2 mms apical to the tooth socket in order to achieve initial
stability and is CONTRAINDICATED in the presence of infection.
•Delayed immediate implantation: Installation of an implant into a healing
socket within 6-12 weeks following extraction. Peak osteoclastic activity is 6-8
weeks’ post extraction and may lead to auto exposure of the implant.
Osteoblastic activity then follows.
•Delayed implantation: Placed 6-12 months following tooth extraction

41. IMMEDIATE IMPLANTATION
An implant is placed into a fresh extraction socket.
Advantages
•Two steps in one operation.
•Less discomfort to the patient.
•Time saving.
•Bone resorption in edentulous areas is diminished.
Disadvantages
•No mucosal closure is necessary.
•Greater risk of fibrointegration rather than osseointegration
•The auxiliary need of membranes and/or synthetic bone increases cost to the patient.

42. IMMEDIATE IMPLANTATION
Requirements
•Absence of any acute infection.
•Sufficient alveolar bone must be present.
Indications
•Coronal or root fracture of an incisor in a young patient of more than 18 years of age
following trauma
•Fractured root or non-restorable tooth or root stumps.
•Periodontally involved teeth without acute infection.
•Root fracture due to post stresses.

43. IMMEDIATE IMPLANTATION
Time line for healing in immediate implantation procedures
•Maxilla Ô 6 months.
•Mandible Ô 3 months.
•Implantation Ô should not be before 3-4 months following bone transplantation.

44. CRITERIA OF SUCCESS FOR OSSEOINTEGRATION
1. Implant is clinically immobile.
2. No radiographic evidence of peri-implant radiolucency.
3. The mean vertical bone loss is < 0. 2 mm / year after the 1st year of
function.
4. No persistent pain, discomfort, infection, numbness, maxillary sinus
or nasal symptoms is attributable to the implant.
5. Resonance frequency analysis RFA.

45. Resonance frequency analysis RFA.
• Resonance frequency analysis is a technique for implant stability
measurements.
• This technique measure the resonance frequency of a transducer attached to
the implant.

46. Resonance frequency analysis RFA.
• The RF is mainly determined by the stiffness of the bone/implant interface
system and the distance from the transducer to the first bone contact.
• The technique can measure and detect:
 Variation in implant stability.
 Small changes in marginal bone level.
• Measurements were originally given in Hs, but when the device known as
OSTELL become available, measurements have been given in ISQ units or
implant stability quotient.
• An ISQ of 60-65 is considered a safe level for loading.

47. THE ALL-ON-4 CONCEPT
• The concept benefits from the posterior tilting of the two distal implants
with a maximum of a two- teeth distal cantilever in the prosthesis.

48. THE ALL-ON-4 CONCEPT
ANATOMICAL INCLUSION CRITERIA FOR MAXILLA
•Crestal bone ridge of at least 4 mm width and at least 10 mm height from
canine to canine
ANATOMICAL INCLUSION CRITERIA FOR MANDIBLE
•crestal bone ridge of at least 4 mm width and at least 8 mm height in the
inter- foramina area.

49. THE ALL-ON-4 CONCEPT
TYPE OF ALL ON 4 SURGICAL APPROACH
1. All-on-4 standard
•Uses two implants placed in the standard axial position and two posterior
implants tilted 45" distally to overcome anatomical limitations.
•The placement follows the maxillary anterior sinus wall and the anterior loop
of the mandibular mental nerve in the mandible.
•

50. THE ALL-ON-4 CONCEPT
TYPE OF ALL ON 4 SURGICAL APPROACH
2. All-on-4 hybrid
•Maxillary anchored implants are used in conjunction with extra- maxillary
anchorage implants (anchored in the zygoma).
•

51. THE ALL-ON-4 CONCEPT
TYPE OF ALL ON 4 SURGICAL APPROACH
3. All-on-4 extra-maxilla

52. THE ALL-ON-4 CONCEPT
ADVANTAGES OF ALL-ON-4 CONCEPT
•The all-on-4 surgical protocol allows fixed rehabilitation of edentulous patients
without the use of complex surgeries for bone regeneration grafting.
•Less invasive.
•Less costly.
•It allows the use of fewer implants.
•Patients who previously were not candidates for implant rehabilitation may
benefit from this treatment.

53. CAUSES OF FAILURE OF OSSEOINTEGRATION
1. Overheating of bone (traumatic surgery) above 44°
C.
2. Oversize or undersize recipient bed preparation.
3. Oversize preparation leads to loosen implant and lack of initial stability.
4. Undersize preparation Ô exertion of excessive pressure on insertion and
stress cracks in bone that delays or prevents osseointegration.
5. Premature loading of the implant.
6. Downward invagination of epithelium and pocket formation (common in
one stage implant system).

54. QUICK TIPS FOR IMPLANT HYGIENE MAINTENANCE
1. Continuing care every three months for the first 2 years
2. Metal scalers are contraindicated. Use nylon, plastic, carbon or resin scalers
specially designed for implant maintenance.
3. Ultrasonic scalers are to be avoided.
4. A soft rubber cup with toothpaste, fine polishing paste or tin-oxide is
recommended.
5. Periodontal probing should be performed only when inflammation or other
pathological symptoms arise.
6. Plaque, calculus, and bleeding indices should be assessed at every visit.
7. Oral hygiene instructions should be assessed and 1 at every visit.
8. Radiographs should be taken at baseline and then every 12 months.

55. THANK YOU