basic implant course for junior dentists to start their career with dental implants

1. Basic implantology
Ali Alkhayat

2. PARTS OF DENTAL IMPLANT

3. Implant Body or
Fixture: the component
that is placed within the
bone during first stage of
surgery.
Abutment
Is the part of implant, which
resembles a prepared tooth, and is
designed to be screwed into the
implant body via Abutment screw
It is the primary component, which
provides retention to the
prosthesis
crown :
replicate the original teeth to
provide a biting surface and
aesthetic appearance
Crown: Material Used:
Porcelains (metal supported
or metal free) or metal
(normally gold)
Abutment: Materials Used:
Titanium.
Implant Body or Fixture:
Materials Used: Titanium &
titanium oxide

4. Healing screw (First stage cover
screw)
 It is placed into the top of the implant to
prevent bone ,soft tissue or debris from
invading the abutment connection area
during healing.
 It facilitates suturing of the soft tissue
4

5. Healing abutment
 It is a temporary part placed on the implant
body to create a channel through the mucosa
while the adjacent soft tissues heal and results
in a perimucosal seal around the implant.
 Also called as permucosal extension or
gingival former.
5

6. Impression posts/coping:
Is a small stem that facilitates the transfer of the
intraoral location (of the implant or the abutment) to a
similar position on the cast.
They are screwed into implant body during impression
making.

7. Analogue or Implant Replica
Analogues are used by laboratory technicians to
replicate implants and their position in a
patient’s mouth.
The analogue,screwed onto the impression coping,
is set into the plaster model during casting

8. Implant body
 The component that is
placed within the bone
during first stage of
surgery
 It could be threaded or
non threaded, with or without
a hydroxyapatite coating

9. Implant abutment
Intermediate connector between the
implant and the restoration, it may
extend above the tissue.
Supports or retains a prosthesis.
4 types: cylindrical, shouldered,
angled and customizable
Shouldered designs provide natural-
appearing emergence profile
9

13. PRETREATMENT EVALUATION
Chief complaint
Medical history MEDICATIONS, ALLERGIES SOCIAL
HISTORY , FAMILYHISTORY
Dental history
A thorough clinical assessment should be undertaken for every patient
before undergoing therapy.

14. Chief complaint
Problem or concern in the patient’s own words
Patients goal of treatment
How realistic are the patients expectations
History of present illness
If the patient has been referred…the extent of the desired
treatment has to be defined, referring dentist informed of the
expectations regarding the outcome.

15. Medical history
Cardiovascular system
Respiratory system
Central nervous system
Digestive system
Endocrine system
Hematopoietic system
Genitourinary system
Allergies
Bones & joints
Neoplasm
Menopause
Pregnancy
Medications

16. Medical history
Gender..no influence on the outcome.
Women after menopause more prone to develop
osteoporotic conditions.
(Lekholm et al. 1994, Friberg et al. 1997, Sennerby &
Rasmusson 2001)

17. Medical history
Age..no influence.. In osseointegration..implants become
bone anchored both in young& elderly individuals
(Kondell et al. 1988, Jemt 1993)
Still…elderly patients more susceptible to infections… slow
healing ..
(Sermerby & Rasmusson 2001)

18. Medical history
Growing individuals… rather react like ankylotic
teeth...infra-occlusion
(Oilman 1994)
Not the chronological age but dental/skeletal maturation
considered in adolescents.
(Thilander et al. 1994)
Radiographs of the hand bones..
Psychosocial reasons …
(Koch et al. 1996)

19. Dental history
A history of recurrent or frequent abscesses…indicate
susceptibility to infections or diabetes.
Presence of a number of restorations, compliance with
previous dental recommendations, the patient’s current oral
hygiene practices noted.
The individuals past experience with surgery & prosthetics,
or any dissatisfaction with past treatment should be
discussed.

20. Extra-oral parameters
1. Facial proportions
2. Facial symmetry
3. Need for lip & cheek support
4. Facial skeletal classification
5. Intermaxillary relation
6. Incisal edge position of the maxillary centrals & occlusal
plane
7. Neurologic test to serve as a baseline assessment in case of
intraoperative nerve lesions
8. TMJ movement & function

21. Systemic examination
Baseline vital signs
- Blood pressure
- Pulse
- Respiration
- temperature

22. INTRAORAL EXAMINATION
Amount of resorption of edentulous ridge
Size & shape of edentulous ridge
Quality of tissue
Inter occlusal space
Jaw relationship
Floor of mouth
Amount of hard tissue
Soft tissue pathology
Patients oral hygiene

23. BONE EVALUATION
Available bone :is the amount of bone in the edentulous area
considered for implantation
it is measured in :
•width
• height
• length
• angulation
• crown : implant

24. Maxillary canine eminance -- greater height of alveloar bone than max ant or
post region
Mand canine & premolar reduced height than anterior  anterior loop of
mandibular canal

26. Available bone angulation:
Ideally it is aligned with the forces of occlusion & is parallel to thelong
axis of prosthodontic restoration
angulation of force b / w the body & the abutment of an implant is
correlated with the width of the bone. wider ridge -30degreeangulation.
The narrow width ridge- requires a narrower design root formimplant
which cause greater crestal stress – so the acceptable angulation is20

27. Resorption pattern
A. abundant bone
B.Adequate bone height, but reduced bone width
B-w – require bone grafting
C-w –Advanced bone width reduction
C-h -Advanced bone height loss
D -is severe atrophy By Mish & Judy
(1990)

28. Misch classification on bone density(1988)
D5 Immature, nonmineralized bone

30. • Photographs
• Study models
• Radiographs
• Diagnostic waxup

31. Photographs
Intra oral & Extra oral photographs
should be taken pre-operatively,
intra-operatively &
post- operatively
Diagnostic cast
•Assist in implant site selection
&angulation requirements during
surgical phase
• surgical template
•used for presentations to motivate
the patient acceptance of the
proposed treatment

32. RADIOGRAPHIC
EXAMINATION Phase I  pre surgical
implant imaging
Phase II  surgical and intra
operative implant imaging
Phase III  post prosthetic
implant imaging
OBJECTIVE
• Identify disease
•Determine bone
quantity
• Determine bone
density
•Identify critical
structures at the
proposed implant
regions
•Determine the
optimum position
of implant

34. IMAGING MODALITIES
Periapical radiography
Panoramic radiography
Occlusal radiography
Cephalometric radiography.
Interactive computed tomography
Magnetic resonance imaging

42. Interactive CT in conjunction
with a surgical guide stent, can
help guide dental implant
placement into the ideal
position with respect to function
and esthetics.

43. The Panoramic view is
similar to a normal two
dimensional panoramic
view
There Are 3 Basic Views Available On The Screen And
A three Dimensional View

44. The axial view offers a
perspective from a
coronal/apical direction.
There is a cross
sectional view that
allows a mesial/distal
perspective of the arch.

45. Enhanced treatment plan and reduced risk of errors.

46. All three of these views
correlate to each other
When a marker is
moved on one view it
corresponds to the other
two views. The final
perspective is a 3
dimensional view
The 3 dimensional view allows the clinician to check for
parallelism of implants.

47. Radiographic stent
Radiographic stent - (can double as surgical stent)
Acrylic stent with lead beads or ball -bearings (5mm) placed
in proposed fixture locations, allows more accurate
radiographic interpretation

48. Edentulous jaw
Clear Acrylic Stent
RPD
Impression

49. Place Metal Tubes in the Stent Make a Radiograph
Stent for surgery

50. Implants With Natural Teeth
On average we need 6 to 7
mm of mesiodistal dimension
to perfectly put an ordinary
implant . But in the extreme
,this can sometimes be
reduced to 5 mm.
When occluding, a minimum
interarch distance must be at
least 5 mm to harbor the implant
supported restoration. The
smallest interdental space that
can be accepted without
damaging the periodontal support
of neighbouring teeth is around 7
mm, if implants of about 4mm
diameter are to be used.

56. Inter-arch space:
 Sufficient inter-arch space is
necessary
 For fixed implant-supported
prosthesis
 7 mm - in the posterior region
 8-10 mm - in the anterior areas.
An implant-retained removable
prosthesis requires at least 12 mm.
8-10mm
12 mm
7mm

57. Adjacent teeth:
Rule:
At least 7 mm between two
adjacent teeth.
Adjacent teeth must be
infection free:
 all restorative, periodontal,
and endodontic procedures
should be completed prior to
implant planning.
7 mm
7 mm

58. Esthetic evaluation:
 Smile line analysis is critical
for maxillary anterior
implants

59. Use of stone cast models:
The final step of clinical
assessment …impressions
for stone cast models
Used during treatment
planning….surgical
position & direction
stents.

60. Diagnostic casts & working models provide information
about the existing oral conditions not apparent during the
oral examination.
Helps design optimal occlusal contact.
Selection of the implant design
Diagnosis & fabrication of implant positioning devices.

61. Evaluate prosthodontic criteria in the absence of
the patient:
Occlusal centric relation position, including
premature occlusal contacts
Edentulous ridge relationships to adjacent teeth
& opposing
arches.
Position of potential natural abutments
including inclination, rotation, extrusion,
spacing, parallelism, & esthetic
considerations

62. Wax-up
The diagnostic wax-up on
the working models
provides a vision of the
emergence & position of
the restoration.

63. RIDGE MAPPING
Evaluating the bucco-lingual bony contour by using a bone
probing technique & a measuring guide.
Measurement procedure to ensure that the diameter of an
endosseous screw implant does not exceed the dimensions
of available bone.

64. The Wilson Bone Caliper
Adaptable for measuring
in both anterior &
posterior regions of the
mandible & maxilla.
The millimeter scale can
be read from either side.

65. Ridge mapping technique:
Measurement of crestal
width.
2 measurements taken at
each implant site: one at
the level of the ridge crest
& the other at a point
approximately 7 mm
vertically.

66. Perio probe or
an Endo file with
stopper
Trim the cast
Mark and section Transfer the marks
to the cast

67. Assess bone density ??
Bone density  CADIA  Kodak densitometric software

68. Primary implant stability
Initial stability that is achieved at surgery
Prerequisite for implant survival
Prevents the formation of a connective tissue
layer between implant and bone, thus
ensuring bone healing
• Branemark et al. 1977; Adell et al. 1981; Albrektsson et
al. 1981; Meredith 1998; LioubavinaHack et al. 2006

69. Prosthetic Options
Depending On The Treatment Options (Misch in 1989 )
FP- 1: replaces only the crown; looks like a natural tooth.
FP- 2: replaces the crown and a portion of the root; crown contour
appears normal in the occlusal half but is elongated or hypercontoured
in the gingival half.
FP- 3: replaces missing crowns and gingival color and portion of the
edentulous site; prosthesis most often uses denture teeth and acrylic,
but may be made of porcelain, or metal.
RP-4: overdenture supported completely by implant.
RP-5: overdenture supported by both soft tissue and implant.

72. Patient preparation
Implant site
preparation
One stage Vs two
stage implant surgery

73. 1. Explanation of risks and benefits to the
patient.
2. Written / Informed consent
3. Local or General Anesthesia depending
on patient’s needs.

74. 1. Implants must be sterile and made of a biocompatible material
(e.g., titanium).
2. Implant site preparation should be performed under sterile
conditions.
3. Implant site preparation should be completed with an atraumatic
surgical technique that avoids overheating of the bone during
preparation of the recipient site.
4. Implants should be placed with good initial stability.

75.  Slow speed
 Adequate cooling
 Bone cutting speed of less than 2000 rpm
 Using sharp drills
 The optimal torque threshold – 35 N/cm.
 Implant should gently engage the bone in order to avoid
too much pressure at the bone interface which could
jeopardize healing
 Surgical skill / technical excellence

76. 1. Patient toweling
2. Rinsing or swabbing the mouth with chlorhexidine
gluconate for 1 to 2 minutes immediately before the
procedure.
3. Atraumatic implant site preparation.
4. Avoid damage to bone or vital structures
5. Copious irrigation
6. The implant must be placed in healthy bone.
7. The surgical site should be kept aseptic.

77. 1. Good operating light
Good high volume suction
A surgical drilling unit which can deliver relatively high speeds (up to 3000
rpm) and low drilling speeds (down to about 10 rpm) with good control of
torque and irrigation system .
The appropriate surgical instrumentation .
Sterile drapes, gowns, gloves, suction tubing etc.
2.
3.
4.
5.
6.

78. 9. The complete radiographs including tomographs
10. A trained assistant
11. Light handles should be autoclaved or covered with
sterile aluminum foil.
12. The instrument tray and any other surfaces which
are to be used are covered in sterile drapes.

80. In the one-stage
approach, the implant or
the abutment emerges
through the
mucoperiosteum/gingival
tissue at the time of
implant placement.

81. Easier Mucogingival management around
the implant.
Patient management is simplified because
a second stage exposure surgery is not
necessary.

82. In the two-stage approach, the top of the
implant and cover screw are completely
covered with the flap closure.
Implants are allowed to heal, without loading
or micro movement, for a period of time to
allow for osseointegration.
The implant must be surgically exposed
following an undisturbed healing period.

83. In areas with dense cortical bone and good initial
implant support, the implants are left to heal
undisturbed for a period of 2 to 4 months, whereas
in areas of loose trabecular bone, grafted sites, and
sites with lesser implant stability, implants may be
allowed to heal for periods of 4 to 6 months or more.
In the second-stage (exposure) surgery, the implant
is uncovered and a healing abutment is connected
to allow emergence of the implant/abutment
through the soft tissues, thus facilitating access to
the implant from the oral cavity.

84. Situations that require simultaneous bone
augmentation procedures at the time of implant
placement because membranes can be covered by
primary flap closure, which will minimize
postoperative exposure.
Prevents movement of the implant by the patient, who
may inadvertently bite on the healing abutment during
the healing period (one-stage protocol).
Mucogingival tissues can be augmented if desired at
the second-stage surgery in a two-stage protocol.

85. The first stage ends by:
Suturing
So the implant remains submerged and isolated
from the oral cavity.
Mandible implants – 2 to 4 months
Maxillary implants – 4 to 6 months
Longer periods –
less dense bone
Less initial implant stability
Shorter periods –
More dense bone
Altered surface microtopography

86. In the second stage
The implant is uncovered and a healing
abutment is connected to allow emergence of
the implant through the soft tissue, thus
facilitating access to the implant from the oral
cavity.

87. Flap design, incisions, and elevation
Vary slightly depending on the location and
objective of the planned surgery.
Crestal
 The incision is made from along the crest of the
ridge, bisecting the existing zone of keratinized
mucosa
 Adv. Easy to manage, results in less bleeding, less
edema, faster healing.
 Suturing placed generally do not interfere with the
healing.
Remote
 The incision is made some distance from the planned
osteotomy site.
 Layer suturing is indicated to minimize the bone
graft exposure.

89. A mucoperiosteal (full-thickness) flap is
reflected up to or slightly beyond the level of
the mucogingival junction, exposing the
alveolar ridge of the implant surgical sites.
Elevated flaps may be sutured to the buccal
mucosa or the opposing teeth to keep the
surgical site open during the surgery.
The bone at the implant site(s) must be
thoroughly debrided of all granulation tissue.

90. Once the flaps are reflected and the bone is
prepared (i.e., all granulation tissue removed
and knife-edge ridges flattened), the
implant osteotomy site can be prepared.
A series of drills are used to prepare the
osteotomy site precisely and incrementally
for an implant.

92. Tissue management f or a two-
stage implant placement.
A, Crestal incision made along the
crest of the ridge,
bisecting the existing zone of
keratinized
mucosa.
B, Full-thickness flap is raised buccally
and lingually to the level of
the mucogingival junction.
A narrow, sharp ridge can be
surgically reduced/contoured to
provide a reasonably flat bed for
the implant.
C, Implant is placed in the
prepared osteotomy site.
D, Tissue approximation
to achieve primary flap
closure without tension

93. Sequence of drills used for
standard-diameter (4.0-
mm) implant site
osteotomy preparation:
round,
2 mm twist,
pilot,
3mm twist, and
countersink.
Bone tap (not shown here)
is an optional drill that is
sometimes used in dense
bone
before implant
placement.

94. A small round bur (or spiral drill) is used to mark
the implant site(s).
Slight modifications may be necessary to adjust
spatial relationships and to avoid minor ridge
defects.
Each marked site is prepared to a depth of 1 to 2
mm with a round drill, breaking through the
cortical bone and creating a starting point for the
2-mm twist drill.

107. As the final step in preparing the osteotomy site
in dense cortical bone, a tapping procedure may be
necessary.
With self-tapping implants being almost
universal, there is less need for a tapping
procedure in most sites.
However, in dense cortical bone or when placing
longer implants into moderately dense bone, it is
prudent to tap the bone (create threads in the
osteotomy site) before implant placement to
facilitate implant insertion.
.
35

108. It is better to allow the threaded implant
to “cut” its own path into the osteotomy
site.
Bone tapping and implant insertion are
both done at very slow speeds (e.g., 20
to 40 rpm). All other drills in the
sequence are used at higher speeds
(800 to 1500 rpm).

109. In partially edentulous cases, limited jaw opening or proximity to
adjacent teeth may prevent appropriate positioning of the
drills in posterior edentulous areas.
In fact, implant therapy may be contraindicated in some patients
because of a lack of inter occlusal clearance, lack of interdental
space, or a lack of access for the instrumentation.
Therefore a combination of longer drills and shorter drills, with
or without extensions, may be necessary.
Anticipating these needs before surgery facilitates the
procedure and improves the results.

110. Implant site preparation (osteotomy ) for a 4.0-mm diameter, 10 mm
length screw-type, threaded (external hex) implant in a subcrestal
position.
A, Initial marking or preparation of the implant site with a round bur.
B, Use of a 2-mm twist drill to establish depth and align the implant.
C, Guide pin is placed in the osteotomy site to confirm position and
angulation.
D, Pilot drill is used to increase the diameter of the coronal aspect of
the osteotomy site.

111. E, Final drill used is the 3 - mm twist drill to finish preparation of the osteotomy
site.
F, Countersink drill is used to widen the entrance of the recipient site and allow
for the subcrestal placement of the implant collar and cover screw.
G, Implant is inserted into the prepared osteotomy site with a handpiece or
handheld driver.
H, Cover screw is placed and soft tissues are closed and sutured

121. Once the implants are inserted and the cover screws secured,
the surgical sites should be thoroughly irrigated with sterile
saline to remove debris and clean the wound.
Proper closure of the flap over the implant(s) is essential.
One of the most important aspects of flap management is
achieving good approximation and primary closure of the
tissues in a tension free manner.
This is achieved by incising the periosteum (innermost layer of
full- thickness flap), which is non-elastic.
Once the periosteum is released, the flap becomes very elastic
and is able to be stretched over the implant(s) without tension.

122. One suturing technique that consistently provides the
desired result is a combination of alternating
horizontal mattress and interrupted sutures.
Horizontal mattress sutures evert the wound edges
and approximate the inner, connective tissue surfaces
of the flap to facilitate closure and wound healing.
Interrupted sutures help to bring the wound edges
together, counterbalancing the eversion caused by the
horizontal mattress sutures.

131. Simple implant surgery in a healthy patient usually
does not require antibiotic therapy.
However, patients can be premedicated with
antibiotics (e.g., amoxicillin, 500 mg three times a
day [tid]) starting 1 hour before the surgery and
continuing for 1 week postoperatively if the surgery
is extensive, if it requires bone augmentation, or if
the patient is medically compromised.
Postoperative swelling is likely after flap surgery.

132. As a preventive measure, patients should apply an ice
pack to the area intermittently for 20 minutes (on and
off) over the first 8 to 24 hours.
Chlorhexidine gluconate oral rinses can be prescribed
to facilitate plaque control, especially in the days after
surgery when oral hygiene is typically poorer.
Adequate pain medication should be prescribed
(e.g., ibuprofen).

133. Patients should be instructed to maintain a
relatively soft diet after surgery.
Then, as soft tissue healing progresses, they can
gradually return to a normal diet.
Patients should also refrain from tobacco and
alcohol use at least 1 week before and several
weeks after surgery.
Provisional restorations, whether fixed or
removable, should be checked and adjusted so
that impingement on the surgical area is avoided.

134. For implants placed using a two-stage
“submerged” protocol, a second-stage
exposure surgery is necessary after the
prescribed healing period.
Thin soft tissue with an adequate amount of
keratinized attached gingiva, along with good
oral hygiene, ensures healthier peri- implant
soft tissues and better clinical results

135. 1. To expose the submerged implant without
damaging the surrounding bone.
2. To control the thickness of the soft tissue
surrounding the implant.
3. To preserve or create attached keratinized tissue
around the implant.
4. To facilitate oral hygiene.
5. To ensure proper abutment seating.
6. To preserve soft tissue aesthetics.

136. In areas with sufficient zones of keratinized tissue,
the gingiva covering the head of the implant can be
exposed with a circular or “punch” incision
Alternatively, a crestal incision through the middle
of the keratinized tissue and full-thickness flap
reflection can be used to expose implants.
This latter approach may be necessary when bone
has grown over the implant and needs to be
removed.

140. Clinical view of stage two, implant exposure surgery in a case with
adequate keratinized tissue.
A, Simple circular “punch” incision used to expose implant when
sufficient keratinized tissue is present around the implant(s).
B, Implant exposed.
C, Healing abutment attached.
D, Final restoration in place, achieving an esthetic result with a
good zone of keratinized tissue. 55

141. Clinical v iew of stage two implant exposure surgery in a case with inadequate
keratinized tissue.
A, Two endosseous implants were placed 4 months previously and are ready
to be exposed.
B, Two vertical incisions are connected by crestal incision.
C, Buccal partial thickness flap is sutured to the periosteum apical to the
emerging implants.
D, Gingival tissue coronal to the cover screws is excised using the
gingivectomy technique.
E, Cover screws are removed, and heads of the implants are cleared.
F, Abutments are placed. Visual inspection ensures intimate contact between
the abutments and the implants.

142. G, Healing at 2 to 3 weeks after second-stage surgery .
H, Four months after the final restoration. Note the healthy band
of keratinized attached gingiv a around the implants.

143. If a minimal zone of keratinized tissue exists
at the implant site, a partial-thickness flap
technique can be used to fulfill the objective
of the second-stage surgery (exposing the
implant) while increasing the width of
keratinized tissue.
A partial-thickness flap is then raised in such a
manner that a nonmobile, firm periosteum
remains attached to the underlying bone. The
flap, containing a narrow band of keratinized
tissue, is then repositioned to the facial side of
the emerging head of the implant and sutured
to the periosteum with a fine needle and
resorbable suture such as a 5.0 gut suture

144. A partial-thickness flap is apically
displaced and sutured to the
periosteum without exposing the
alveolar bone.
A free gingival graft may be harvested
from the palate and sutured to the
periosteum on the labial surface of the
implants to increase the zone of
keratinized tissue.

145. A, Partial-thickness f lap is created from the lingual aspect of the
crest toward the labial surf ace in order to preserve the keratinized
tissue on the crest (over the implant). note: This tissue might be
excised in a simple implant exposure.
B, The split-thickness f lap is repositioned to the labial surf ace.
C, The f lap is sutured to the periosteum at a more apical position
preserving the amount of keratinized tissue (arrows).
Finally , the remaining connective tissue over the cover screw (B) is
excised with a sharp blade to expose the implant. Care should be
taken to avoid removing keratinized tissue from the lingual aspect of
the implant.

146. After the flap is repositioned and secured
with periosteal sutures, the excess tissue
coronal to the cover screw is excised,
usually with a surgical blade.
When the excess tissue over the cover
screw is removed or displaced, the outline
of the cover screw is visible.
A sharp blade is used to eliminate all
tissues coronal to the cover screw.
The cover screw is then removed, the head
of the implant is thoroughly cleaned of any
soft or hard tissue overgrowth, and the
healing abutments or standard abutments
are placed on the implant

147. remind the patient of the need for good oral
hygiene around the implant and adjacent teeth.
rinse can be used to enhance oral hygiene for the
initial few weeks after implant exposure.
oral hygiene procedures to avoid dislodging any
repositioned or grafted soft tissues.
any direct pressure or movement directed
toward the soft tissue from a provisional
prosthesis can delay healing and should be
avoided.

148. Impressions for the final prosthesis
fabrication can begin about 2 to 6 weeks
after implant exposure surgery, depending
on healing and maturation of soft tissues.

150.  In the one-stage implant surgical approach, a second
implant exposure surgery is not needed because the
implant is exposed (per gingival) from the time of
implant placement
 In the standard (classic) implant protocol, the
implants are left unloaded and undisturbed for a
period similar to that for implants placed in the two-
stage approach
(i.e., in areas with dense cortical bone and good
initial implant support, the implants are left to
heal undisturbed for a period of 2 to 4 months,
whereas in areas of loose trabecular bone, grafted
sites, and/or minimal implant support, they may be
allowed to heal for periods of 4 to 6 months or
more).

151. In the one-stage surgical
approach, the implant or the
healing abutment protrudes
about 2 to 3 mm from the bone
crest, and the flaps are adapted
around the implant/abutment.

152. The flap design for the one-stage surgical
approach is always a crestal incision bisecting
the existing keratinized tissue.
Facial and lingual flaps in posterior areas
should be carefully thinned before total
reflection to minimize the soft tissue
thickness (if needed or desired).
The soft tissue is not thinned in anterior or
other esthetic areas of the mouth to
maintain tissue height and to minimize
metallic implant components from showing
through tissue.

153. The primary difference is that the coronal
aspect of the implant or the healing
abutment (two-stage implant) is placed
about 2 to 3 mm above the bone crest
and the soft tissues are approximated
around the implant/implant abutment.

154. The keratinized edges of the flap are sutured
with single interrupted sutures around the
implant.
Depending on the clinician's preference, the
wound may be sutured with resorbable or
nonresorbable sutures.

155. The postoperative care for one-stage
surgical approach is similar to that for the
two-stage surgical approach except that
the cover screw or healing abutment is
exposed to the oral cavity.
Patients are advised to avoid chewing in
the area of the implant.
Prosthetic appliances should not be used
if direct chewing forces can be
transmitted to the implant, particularly in
the early healing period (first 4 to 8
weeks).

156. Criteria for success

157. Revised criteria - Albrektsson
Individual implant is immobile clinically
No evidence of peri-implant radiolucency is
present as assessed on an undistorted
radiograph.
Mean vertical bone loss is less than 0.2 mm
annually after the first year of service.

158. No persistent pain, discomfort, or infection is
attributable to the implant.
Implant design does not preclude placement of
a crown or prosthesis with an appearance that is
satisfactory to the patient and dentist.
By these criteria, a success rate of 85% at the
end of a 5-year observation period and 80% at
the end of a 10 year period are minimum levels
for success.

160. Introduction
• Implantology is an ever growing field.
• Nevertheless, it has, as every surgical
procedure, several complications that can
occur and that must be known in order to
prevent or solve them.
• It is mandatory to classify all those clinical
complications that can arise.

161. • Accidents are events that occur during surgery
Accidents always happen during surgical procedures.
• Complications appear lately, once surgery is already
performed. There are two kinds of complications,
depending on the time they emerge: early and late.
• Early-stage complications appear in the
immediate postoperative period and interfere
with healing,
• Late-stage complications arise during the process
of osseointegration.

162. • Failures occur when the professional and/or
the patient do not obtain the desirable
results

163. Localcomplications in dental implant surgery
• Infection
• Edema
• Ecchymoses and haematomas
• Emphysema
• Bleeding
• Flap dehiscence
• Sensory disorders

164. • Perforation of the mucoperiosteum
• Maxillary sinusitis
• Mandibular fractures
• Failed osseointegration
• Bony defects
• Periapical implant lesion
(Misch and Wang,2008)

165. CLASSIFICATION (Carranza)
• Surgical complications
• Biologic complications
• Technical or mechanical
complications
• Esthetic and phonetic complications

166. Surgical
complications
• Hemorrhage and hematoma
• Neurosensory disturbances
• Damage to adjacent teeth
Biologic
complications
• Inflammation
• Dehiscence and recession
• Periimplantitis and bone loss
• Implant loss or failure

167. Technical
complications
• Screw loosening and fracture
• Implant fracture
• Fracture of restorative
materials
Esthetic and
phonetic
complications
• Esthetic complications
• Phonetic complications

168. Bleeding
• Common accident as a consequence of local-anatomical
or systemic causes.
Causes of bleeding:
lesions in any sublingual, lingual, perimandibular,
or submaxillary artery
Surgeries in the lower and anterior area of totally
edentulous patients who have a deficit in the quality and
quantity of bone.

169. • More prone patients fall in the following category:
Group 2 of medical-systemic risk:
 Irradiated patients (radiotherapy),
 Patients with coagulation disorders (anticoagulated
patients or those with haemostatic disorders)
(Buser et al., 2000)

170.  Patients with serious systemic diseases (rheumatoid
arthritis, osteomalacia, imperfect osteogenesis),
 Immunodepressed (HIV, immunosupresory
treatments),
 Drug addicts (alcohol, etc.),
 Unreliable patients (mental or psychological
disorders).

171. Therapeutic options in these patients comprise two
approaches:
Decrease or eliminate the anticoagulant therapy once
patient and physician have assessed risks and benefits.
Invasive treatments can be performed ( Bacci et
al., 2010):
International Normalized Ratio (INR) are less than 4,
and
Adequate hemostatic measures are followed and,
Use atraumatic surgery techniques;

172. Treatment: local intraoperative or postoperative
measures
Local hemostasis (suture, compression, the use of
hemostatic microfibrilar collagen gauzes,
oxidized cellulose, reabsorbable fibrin, or mouth
rinsing with 4,8% of tranexamic acid)

173. • Swelling - more noticeable 24 hours
after performing surgery
• Causes:
Wide flaps,
Bone regenerating techniques, and
surgery time
Edema

174. • Leads to trismus, lack of hygiene in the
wound and discomfort to the patient.
• Decreases with time, and can easily
vanish after a few days.

175. Hemorrhage/ Ecchymosis
• Severe bleeding and the formation of massive
hematomas in the floor of the mouth are the result
of an arterial trauma.
Several types of hemorrhagic patches can develop as a
result of injury:
Petechiae (<2 mm in diameter),
Purpura (2 to 10 mm), and
Ecchymosis (>10 mm).

176. Ecchymosis are the result of an intermental
surgery procedure.

177.  Swelling and elevation of floor of the mouth
 Increase in tongue size
 Difficulty in swallowing or speech
 Pulsating or profuse bleeding from the floor of the
mouth or the osteotomy site

178. Emphysema
• Rare complication, though it can lead to severe
consequences (McKenzie & Rosenberg, 2009).
• Causes
Inadvertent insufflation propulsion of air into tissues
under skin or mucous membranes,
Air from a high-speed handpiece, air/water syringe, an
air polishing unit or an air abrasive device can be
projected into a sulcus, surgical wound, or a laceration in
the mouth
(Liebenberg & Crawford, 1997)

179. Neurosensory disturbances
• Nerve lesions are both an intraoperative accident and
a postoperative complication that can affect the
infra-orbital nerve, the inferior alveolar nerve, or its
mental branch and the lingual nerve.

180. Several implants in contact to the Inferior
Alveolar nerve in patients with postoperative
paresthesia.

181. Causes
• INDIRECT
Postsurgical intra-alveolar edema or hematomas- produce
a temporary pressure increase, especially inside the
mandibular canal
• DIRECT
Compression, stretch, cut, overheating, and accidental
puncture
(Annibali et al., 2009)

182. • Poor flap design,
• Traumatic flap reflection,
• Accidental intraneural injection,
• Traction on the mental nerve in an elevated
flap,
• Penetration of the osteotomy preparation
• Compression of the implant body into the
canal
(Misch & Wang, 2008).

183. The nerve injury may cause one of the following
conditions:
• Parasthesia (numb feeling),
•Hypoesthesia (reduced feeling), hyperesthesia
(increased sensitivity),
• Dysthesia (painful sensation), or
• Anesthesia (complete loss of feeling) of the teeth,
the lower lip, or the surrounding skin and mucosa
(Greenstein & Tarnow, 2006 as cited in Sharawy &
Misch, 1999).

184. Recommendations to avoid nerve injuries during
implant placement (Worthington,2004)
Be sure to include nerve injury as an
item in the informed consent
document.
Measure the radiograph with care.
Use coronal true-size tomograms
where needed.
Allow a 1 to 2 mm safety zone.
Use a drill guard.
Apply the correct magnification
factor.
Consider the bony crestal anatomy:
Take care with countersinking not to
lose support of the crestal cortical
bone.
Is the buccolingual position of the
crestal peak of bone influencing the
measurement of available bone?
Consider the buccolingual position of
the nerve canal.
Keep the radiograph and the
calculation in the patient’s chart as
powerful evidence of meticulous patient
care.

185. • Treatment (Misch & Resnik, 2010).
• Too much proximity between the implant and a nerve-
removal as soon as possible
• Treatment with corticosteroids and non-steroidal anti-
inflammatory drugs - to control inflammatory
reactions that provoke nervous compression.
• Topical application of dexamethasone (4 mg/ml) for 1
or 2 minutes enhances recovery,
• Oral administration (high doses)- within one week of
injury- prevention of neuroma formation

186. • Intraoperative nerve section - microsurgery
techniques to reestablish nerve continuity.
• Neurosensorial loss - checked at different
moments to determine with precision the
evolution of the lesion
• Resort to microsurgery if, after four months -
patient’s situation has not improved, pain
persists and there is a remarkable loss of
sensitivity.

187. Aspiration and swallowing of instruments
Images of a screw driver in the digestive tract. (b)
Screw driver into pulmonary tissue.

188. • Vital emergency if the instrument has entered the
airways.
• Recommended to tie all tiny and slippery instruments
with silk ligatures or else use a rubber dam
(Bergermann et al., 1992).
• Gastroscopy or colonoscopy with a proper medical
follow-up required to locate.

189. Flap dehiscence and exposure of graft material or
barrier membrane
• The most common postoperative complication is wound
dehiscence, which sometimes occurs during the first
10 days (Greenstein et al., 2008).
Wound dehiscence at one week post surgery in a
diabetic patient with oral candidiasis

190. • Flap tension,
• Continuous mechanical trauma or irritation associated
with the loosening of the cover screw,
• Incorrect incisions
• Poor-quality mucosa (thin biotype, traumatized),
• Heavy smokers, patients treated with
corticosteroids, diabetics, or irradiated patients
(Lee & Thiele, 2010)

191. •No surgical correction
Small
dehiscence-
• Resuturing
Large
dehiscence

192. 1) Careful preoperative assessment of the soft tissues
to measure the amount of keratinized mucosa
present and planning of augmentation procedures as
appropriate;
2) Minimally invasive flap elevation and reflection with
careful removal of any bone débris beneath;
3) Proper suturing;
4) Sensible temporization, rebasing and relining; and
5) Delaying the use of removable dentures until two
weeks after surgery.

193. Complications associated with
maxillary sinus lift
• The Schneiderian membrane- characterized by
periosteum overlaid with a thin layer of pseudociliated
stratified respiratory epithelium,
• Constitutes an important barrier for the protection
and defense of the sinus cavity.

194. Schneiderian membrane perforation occurs in
10% to 60% of all procedures

195. Anatomical variations such as a maxillary sinus septum,
spine, or sharp edge are present
Very thin or thick maxillary sinus walls

196. • folding the membrane up against
itself as the membrane is
elevated
Small
tears (<5
to 8 mm)
• do not lend themselves to
closure by infolding
• Repaired with collagen or a
fibrin adhesive
Larger
tears

197. Loss of the implant or graft materials
into the maxillary sinus
Changes in intrasinal and nasal pressures;
Autoimmune reaction to the implant, causing
peri-implant bone destruction and compromising
osseointegration; and
Resorption produced by an incorrect
distribution of occlusal forces
(Galindo et al., 2005)

198. Immediately retrieved surgically via an intraoral
approach or endoscopically via the transnasal route
to avoid inflammatory complications

199. Improper implant location/Implant
displacement
(a) Implant installed . (b) Control CT Scan after
displacement and before second stage surgery. (c)
Change of position.

200. There is an absence or loss of osseointegration and,
Loss of stability
If in the sinus: can be removed a few days later by opening
the lateral wall of the maxillary sinus, or
by endoscopic via through a nasal window.
Accurate surgical technique - using osteotomes to prepare
the implant beds or
a drill with a smaller diameter to that of the fixture, or
using implants with a conical compressive form.

201. Injury to adjacent teeth
• This problem arises more frequently with single implants
A malpositioned implant hitting an adjacent tooth

202. • Damage to teeth adjacent to the implant site-
subsequent to the insertion of implants along
an improper axis or after placement of
excessively large implants.
(Quirynen et al., 2005; Tozum et al., 2006; Zhou et
al., 2009).

203. • Use of a surgical guide, radiographic analysis and CT
scan can help locate the implant placement.
• Inspection of a radiograph with a guide pin at a depth
of 5 mm will facilitate osteotomy angulation
corrections (Greenstein et al., 2008).
• Prevent a latent infection of the implant from the
potential endodontic lesion, endodontic treatment
should be performed

204. Mandibular fracture
Perforation of the lingual cortical
during drilling.
Infrequent complication

205. • Associated with atrophic mandibles
• Central area of the mandible has a greater risk for
this complication
Reduction and stabilization of the fracture with
titanium miniplates or resorbable miniplates.
Splinting implants to reduce and immobilize the fracture
Thin mandibular alveolar crests- increase width by
performing bone grafts
Accurate tomography imaging study

206. Screw loosening
• Incidence- 6%
• Causes:
Stress applied to prosthesis
Crown height
Cantilever
Height or depth of antirotational component
Platform dimensions on which the abutment is seated

207. • Large diameter implants with large platform
dimensions reduce the forces applied to the
screw
• Increase thread tightening

208. IMPLANT EXPOSURE
• Can be associated with exudate and bone loss
:
Complete exposure of the implant cover screw
Removal of the healing cover
Flushing of the implant with chlorhexidine,
insertion of a permucosal extension
Oral hygiene with soft toothbrush
Chlorhexidine application over the area twice
each day

209.  tissue approximated
 Membrane can be used
 Antibiotics and chlorhexidine daily rinses
 Uncovering of implant, removal of cover screw
 Curetting of granulation tissue
 Cleaning of implant surface-diamond bur/ air abrasive
 Bone grafts and membrane

210. Implant fracture
• Infrequent complication (among 0,2 y- 1.5% of cases )
(Eckert et al., 2000)
• Complications is higher in implants supporting fixed
partial prosthesis than in complete edentulous patients.
• Causes:
Defects in the implant design or materials used in their
construction,
A non-passive union between the implant and the
prosthesis or by mechanical overload,

211. Management:
Removal of the implant and its replacement by another one
(a) Implant fractured in maxillary posterior
region. (b) Implants retrieved. (c)
Substitution for a wider diameter in the same
surgery

212. INFECTIONS
PERIIMPLANTITIS
PERIIMPLANT
MUCOSITIS
HYPERPLASTIC
MUCOSITIS
FISTULATIONS
MUCOSAL
ABSCESS

213. Periimplantitis
• Peri-implantitis is defined as an inflammatory
process which affects the tissues around an
osseointegrated implant in function, resulting
in the loss of the supporting bone, which is
often associated with bleeding, suppuration,
increased probing depth, mobility and
radiographical bone loss.

214. • Peri-implant mucositis was defined as
reversible inflammatory changes of the peri-
implant soft tissues without any bone loss
(Albrektsson & Isidor 1994)
In a systematic analysis, 2003
• Incidence of periimplmant mucositis- 8-44%
• Incidence of periimplantitis- 1- 19%

215. Periimplant mucositis

216. Periimplantitis

217. • History of periodontitis
• Smoking
• Poor oral hygiene
• Exposed threads
• Exposed surface coatings (roughened
surfaces)
• Deep pockets (placed too deep, placed into
deficiencies)
•No plaque removal access (ridge lap crown,
connected prostheses)
Risk factors for peri-implantitis

218. Features
Radiological evidence for vertical destruction
of the crestal bone
Saucer shaped defect
Bleeding and
suppuration on
probing
Pain
Formation of a
peri-implant
pocket
Swelling of the
peri-implant
tissues and
hyperplasia

219. Diagnosis
• Clinical indices,
• peri-implant probing,
• bleeding on probing (BOP),
• suppuration,
• mobility,
• peri-implant radiography
• microbiology.

220. Treatment of peri-implant infection
(adapted from Mombelli &Lang2004)
Peri-implant
pockets 3mm
No visible plaque,
No BOP
No therapy
needed
Plaque, BOP
OHI and local
debridement

221. Peri-implant
pockets >3mm
No loss of bone
when compared to
baseline,
No BOP, no visible
plaque
Plaque+/_ BOP
No
therapy
needed
OHI and local
debridement
Surgical
resection

222. Loss of bone
when
compared to
baseline
mild
moderate
severe
OHI and local debridement
Local/systemic antibiotic
delivery
Open debridement
Explantation
OHI and local debridement
Surgical resection
Topical antiseptic
treatment
Local antibiotic delivery
Systemic antibiotic delivery
OHI and local debridement
Topical antiseptic treatment
Local/ systemic antibiotic
delivery
Open debridement

223. • A.
using rubber cups and polishing paster, acrylic scalers
for chipping off calculus.
Effective oral hygiene practices.
• B.
Rinses with 0.1% to 0.2% chlorhexidine digluconate for
3 to 4 weeks.
Cumulative Interceptive Supportive Therapy
(CIST) modalities (Lang et al, 2004).

224. :
1. SYSTEMIC metronidazole (3 x 250
mg/day) for 10 days
OR combination of metronidazole (500 mg/day) plus
amoxicillin (375 mg/day) for 10 days.
2. LOCAL: application of antibiotics using controlled
release devices for 10 days (25% Tetracycline fibers).

225. D. Surgical approach:
• using abundant saline rinses at the defect,
• barrier membranes,
• close flap adaptation and
• careful post-surgical monitoring for several months.
• Plaque control is to be assured by applying
chlorhexidine gels.

226. Esthetic complications
• Depends on patients esthetic
expectations and patient related
factors(bone quantity and quality).
• Depends on individual perceptions and
desires

227. :
Poor implant placement
Deficiencies in the existing anatomy of the
edentulous sites
Crown form, dimension, shape and gingival harmony
is not ideal
Esthetic regions: high esthetic demands, thin
periodontium, lack of hard and soft tissue support
in the anterior esthetic regions

228. Reconstructive procedures to develop a
natural emergence profile of the implant
crown
Appropriate treatment planning and
implementation

229. Phonetic complications
• Implant prosthesis with
Unusual palatal contours ( Restricted or narrow palatal
space)
Spaces under and around the superstructure of implant
Mostly observed in severe atrophied maxilla
Management: implant assisted maxillary- overdenture

230. Postoperative maxillary
sinusitis
• Maxillary sinusitis can occur
Contamination of the maxillary sinus with oral
or nasal pathogens or
via ostial obstruction caused by postoperative
swelling of the maxillary mucosa,
Non-vital bony fragments floating freely in
the maxillary sinus.
Lack of asepsis during sinus augmentation

231. (Timmenga et al., 2001)
Preoperative evaluation of sinus clearance-related
factors
Postsurgery: a nasal decongestant (xylomethazoline
0.05%) and topical corticosteroid (dexamethasone
0.01%) to prevent postsurgery obstruction of the
ostium
Perioperative antibiotic prophylaxis

232. Failed osseointegration
• Osseointegration was originally defined as a direct
structural and functional connection between ordered
living bone and the surface of a load-carrying implant
(Albrektsson et al. 1994).
Osseointegration between an endosseous titanium implant
and bone can be expected greater than 85% of the time
when an implant is placed.

233. Patient(local factors) Oral hygiene
Gingivitis
Bone quantity/quality
Adjacent
infection/inflammation
Presence of natural teeth
Periodontal status of natural
teeth
Impaction of foreign bodies
(including debris from surgical
procedure) in the
implant pocket

234. Patient( systemic factors) Vascular integrity
Smoking
Alcoholism
Predisposition to infection, e.g.
age, obesity, steroid therapy,
malnutrition,
metabolic disease (diabetes)
Systemic illness
Chemotherapy/radiotherapy
Hypersensitivity to implant
components

235. Surgical technique/environment
Surgical trauma
Overheating (use of
handpiece)
Perioperative
bacterial
contamination, e.g.
via saliva, perioral
skin, instruments,
gloves.

236. Thank
you