Dental Implant surgery

1. Implant Dentistry
Basics to Advance
Dr Arslan Mahmood
Assistant Professor
Isra Dental College

2. History What is Implant? Why Implant? Bone Biology
Bone cells Osseointegration Points to remember Implant v/s Natural tooth
One stage vs Two stage Patient Selection Indications
Contraindications
Diagnosis and treatment planning Implant Planning
Anatomic Considerations
Available bone Principles of implant positioning Vertical positioning of the implant
Crown height Available bone height Buccolingual positioning Available bone width
Mesiodistal positioning Rule of 1,2,3 & 7 Angulation of implants
Abutment position
Implant size
Available bone
Implant placement Flap Raised Technique
Flapless Technique Surgical Procedure Suturing the flap Post operative Instructions
Available bone angulation Missing teeth number Implant design Abutment number
Key areas covered

3. History
Throughout the history of civilization, significant value has been seen in the presence
of a complete set of teeth, both for functional and aesthetic reasons.
As early as 2000 BC, early versions of
dental implants were used in the
civilization of ancient China. Eg. Carved
bamboo pegs.
In the 18th century, experiments started with gold and alloys to make implants. These
did not prove to be very successful primarily due to rejection of the foreign body
dental implant. In order for the implant to be successful, the replacement tooth and
the bone need to fuse together.
In 1952 as a part of a research by Dr. Per-Ingvar Branemark’s team surgically
implanted titanium metal pods containing optical devices, into the lower legs of rabbits
to study the healing process within their bones. But when they tried to remove the
metal-framed optics from the bone, he famously discovered that the bone and titanium
had become virtually inseparable. Almost immediately it occurred to Dr. Branemark that
there could be useful applications for this discovery of osseointegration.
3

4. History
Dr. Branemark came up with a way to
implant four pieces of titanium into the
patient’s lower jaw. Until his death 4
decades later the patient used those 4
titanium implants to successfully
anchor a lower denture.
Dr. Branemark is
known as “the
father of
the modern dental
Implantology”
The first titanium dental implant was
placed in a human volunteer in 1965,
Dr Branemark.
4

5. What is Implant

6. What is Implant?
An artificial dental root that is surgically inserted into the jaw bone &
that can be used by the dentist as platform for prosthesis.
6

7. 7
Why Implant?
• To avoid tooth preparation and possible sequelae.
• No need for connectors between pontic and abutment teeth.
• Avoids mechanical risks of conventional bridges.
• Denture retention and support.
FPD RPD
CD

8. 8
What is Implant?

9. Bone Biology

10. Bone Biology
10
A successful treatment in dental Implantology requires the maintenance of the
implant health over long periods of time such that the implant continues to
improve the function of the prosthesis.
Bones are composed of two types of tissue:
1. A hard outer layer called cortical
(compact) bone, which is strong, dense
and tough.
2. A spongy inner layer called trabecular
(cancellous) bone. This network of
trabeculae is lighter and less dense
than compact bone.
Bones in our body are living tissue.
They have their own blood vessels
and are made of living cells, which
help them to grow and to repair
themselves.

11. Cells and composition of Bones
11
Bone is composed of:
Bone forming cells
(osteoblasts &
osteocytes)
Bone resorbing
cells (osteoclasts)
Nonmineral matrix
of collagen and
non-collagenous
proteins (osteoid)
Inorganic mineral
salts deposited
within the matrix
Cells in our bones are responsible
for bone production, maintenance
and modeling:
1. Osteoblasts
2. Osteocytes
3. Osteoclasts

12. Bone matrix and Types of Bones
12
Osteoid is comprised of type I collagen ~94% and non-collagenous proteins. The
hardness and rigidity of bone is due to the presence of mineral salt in the osteoid
matrix, which is a crystalline complex of calcium and phosphate (hydroxyapatite).
Calcified bone contains about 25% organic matrix (2-5% of which are cells), 5%
water and 70% inorganic mineral (hydroxyapatite).
Two types of bone can be identified according to the pattern of collagen
forming the osteoid:
1. Woven bone
2. Lamellar bone
Virtually all bone in the healthy
mature adult is lamellar bone.

13. Bone modeling & Remodeling
13
Modeling is when bone resorption and bone formation occur on separate surfaces. An
example of this process is during long bone increases in length and diameter. Bone
modeling occurs during birth to adulthood and is responsible for gain in skeletal mass
and changes in skeletal form.
Remodeling is the replacement of old tissue by new bone tissue. This mainly occurs in
the adult skeleton to maintain bone mass. This process involves the coupling of bone
formation and bone resorption and consists of five phases:
1. Activation
2. Resorption
3. Reversal
4. Formation: osteoblasts synthesize new bone matrix
5. Quiescence: osteoblasts become resting bone lining cells on the newly formed
bone surface

14. Osseointegration

15. Osseo Integration
15 Osseo Integration is defined as a histological
structural and functional direct contact between
bone and bone marrow with titanium-based
implants without fibrous tissue. The osteotomy
site should heal with intramembranous
ossification without cartilage tissue formation.
Bone in contact with the implant surface undergoes morphological remodeling as
adaptation to stress and mechanical loading.
The turnover of peri-implant
mature bone in Osseo integrated
implants is confirmed by the
presence of medullary or marrow
spaces containing osteoclasts,
osteoblasts, mesenchymal cells
and lymphatic/blood vessels next
to the implant surface.

16. Osseo Integration
16
The mechanisms by which end osseous Implants become integrated in the bone can
be subdivided into three separate phenomena.
They are:
1. Osteo Conduction
2. De novo bone formation
3. Bone remodeling
To obtain implant osseointegration,
primary mechanical stability of the
implant is essential, especially in one-
stage surgical procedures. Primary
mechanical stability consists of rigid
fixation between the implant and the
host bone cavity with no micro-
motion of the implant or minimal
distortional strains.
Excessive implant motion or poor
implant stability results in tensile and
shear motions, stimulating a fibrous
membrane formation around the
implant and causing displacement at
the bone-implant interface, thus
inhibiting osseointegration and
leading to aseptic loosening and
failure of the implant

17. Osseo Integration
17
The successful outcome of any implant procedure is mainly dependent on the
interrelationship of the various components.
1. Biocompatibility of the implant
material
2. Implant surface & designs
3. The status of the implant bed
4. The surgical technique per se
5. The undisturbed healing phase
6. Loading conditions
Once activated; osseointegration follows a common, biologically determined program
that is subdivided into 3 stages:
• Incorporation by woven bone formation
• Adaptation of bone mass to load (lamellar and parallel-fibered bone deposition)
• Adaptation of bone structure to load (bone remodeling).

18. Osseointegration is also a measure of implant stability, which can occur at two
different stages: primary and secondary.
• Primary stability of an implant mainly comes from mechanical engagement with
compact bone.
• Secondary stability, on other hand, offer biological stability through bone
regeneration and remodeling. of an implant.
Osseo Integration
18
Many methods have been tried to clinically demonstrate osseointegration of an
implanted alloplastic material. These are :
1. Performing a clinical mobility test
2. Radiographs demonstrating a apparently direct contact between bone and
implant have been cited as evidence of osseointegration.
3. The use of a metal instrument to tap the implant and analyze the transmitted
sound may, in theory, be used to indicate a proper osseointegration.
4. Clinical application of RFA includes establishing a relationship between exposed
implant length and resonance values or ISQ values.

20. Points to remember
20
1. Titanium is an ideal material for dental implants.
2. Titanium is biologically inert; thus, it does not trigger foreign body reactions.
3. Implant placement kits include designated drills that are used in sequence to
remove the bone as traumatically as possible.
4. Implant insertion is performed in accordance with the normal practices of aseptic
surgery.
5. Limiting thermal damage requires using sharp dental implant drills run at very low
speeds and providing copious cooling irrigation.
6. Ideally, once inserted, the implant should have minimal movement while bone is
allowed to biologically adhere to the implant surface.
7. The primary (initial) stability of an implant at the time of placement depends on
the nature of the bone.
8. Cortical bone provides more primary stability than cancellous bone.
9. Maxilla in general has more spongy bone.

21. Points to remember
21
Lekholm
and Zarb,
1985
Misch,
1988

22. Implant v/s
Natural tooth

23. Implant v/s Natural tooth
23

24. Implant v/s Natural tooth
24

25. COMPONENTS
25
1.Fixtures/Implants
2.Abutments
• Healing
• Basic
• Custom
3.Gold cylinders
4.Analogs/Replicas
• Abutment
•Fixture
5.Impression copings
6.Connection Armamentarium
• Screw drivers
• Guide pins

26. Fixture
Titanium
Different Configurations
• Threaded and Non-threaded
• Cylindrical and Tapered
Different surfaces
• Machined surface
• Enhanced surface
Different Widths
• Narrow, Regular, wide platforms.
Different heads
• External and Internal
26

27. Abutments
• Healing abutment
• Basic abutment
• Standard abutment
• Estheticone abutment
• Angulated abutment
• Mirus cone abutment
• Multiunit abutment
• Custom made abutments
27

28. Basic Abutments
28
ESTHETICONE ABUTMENTS
• Conical abutment
• Hexed connection to fixture
• Collar width 1,2,3 mm
• Improves esthetic potential of restoration
• Seating of the abutment must be verified with an x-ray.
• Design of abutment allows up to 30° non parallelism of fixtures.

29. Angulated abutments
• Corrects screw access for mal-aligned implants, but doesn’t
improve implant loading.
• Internal 12 positions on bottom matches hex on fixture to
prevent rotation and give multiple angle correction
possibilities.
• Can be difficult to use aesthetically.
29

30. Mirus cone
abutment
30
• Shorter height than estheticone abutment
• Allows greater degree of non-parallelism with fixture
placement up to 40°.
Multi unit abutment.
• Same dimensions as mirus cone
• No hex under abutment to facilitate placement
• Only for bridges.
Mirus cone & Multi Unit abutment

31. UCLA Abutments
• Hexed-Engaging
• Non-Hexed-Non Engaging.
Easy abutment
Prepable
• Titanium
• Cemented final restorations
• Straight esthetic
• Angled esthetic
• Ceramic
• Cemented final restoration
• Screw retained
Procera
• Titanium
• Alumina
• Zirconia.
Custom abutment types
31

32. UCLA Abutments
32
was a plastic
• Original UCLA Abutment
castable pattern.
• Improved consistency of fit was developed
with the introduction of a precast and
machined abutment with a waxing sleeve.
• Two types
• Hexed –for single tooth
• Non-hexed –for bridges.
Custom abutments

33. • When inter arch space is limited
• When the fixture angulation is not acceptable
• Follows contours of the soft tissue
• Conventional restorative technique
33
UCLA TYPE ABUTMENT :wax /invest/cast

34. Easy abutment
• Predefined margin
• Snap on impression cap available.
34

35. • Analogs allow the accurate transfer of a facsimile of the
intraoral component to a working model.
• Abutment analog
• Fixture analog
Analog / Replicas
35

36. • Abutment level
• Fixture level
• Linked impression copings.
Impression copings
36

37. Open tray copings
37
• Pick up copings
• Square copings
Closed tray copings
• Transfer copings
• Tapered copings.
Impression copings

38. 38

39. Screw drivers
39

40. Torque drivers
40

41. One stage vs Two stage
41

42. One stage vs Two stage
42

43. 43

44. Patient Selection

45. Patient Selection
45
Indications
 Restore dental aesthetics.
 Restore lost dental function
 Space maintenance and occlusal stability
 Orthodontic anchorage
 Convenience and comfort
 Bone preservation and prevention of disuse atrophy after tooth loss.
Contraindications
 Poorly controlled diabetes
 Immunosuppression
 Untreated periodontal disease
 Radiotherapy to the jaw bone
 Untreated intraoral pathology or malignancy
 Smoking
 Uncontrolled drug or alcohol use (abuse)
 Uncontrolled psychiatric disorders
 Recent myocardial infarction (MI) or cerebrovascular accident (CVA)
 Intravenous bisphosphonate therapy
 Bruxism

46. Diagnosis and treatment planning
46
 Patients presenting complaint and expectations
 Medical history
 Dental and social history
 Extra-oral examination including lip and smile lines
 Intra-oral examination including full periodontal charting
 Bone mapping
 Diagnostic imaging
 Photography
 Written treatment plan and cost estimate
 Patient education and informed consent

49. Implant Planning

50. Surgical Stent Preparation
50

51. Anatomic Considerations
51
• Anterior Mandible – more cortical bone and denser
• cancellous bone – higher implant success as compared to thinner cortical bone
and loose cancellous marrow as in Posterior Maxilla.
• After tooth loss resorption of ridge results in crestal bone thinning and changes
in angulations of the ridge.
• Posterior maxilla – Close approximation of maxillary sinus.
Posterior mandible – implants placed usually shorter, do not engage cortical bone
and must support increased biomechanically occlusal force once loaded. Hence
slightly increased integration time is beneficial. Also more implants than usual
should be placed when using short implants (8-10mm) to withstand occlusal load.
Resorption pattern of maxilla - constriction
Resorption pattern of mandible – flaring of angles.
Premolar area – implant placement anterior to mental foramen. Nerve may be as much
as 3 mm anterior to foramen.

52. Anatomic Considerations
52

53. Available bone
53
It is the amount of bone in the edentulous area considered for implantation.
Measured in :
• Width
• Height
• Length
• Angulation
• Crown/implant ratio

54. Principles of
Implant
Positioning

55. Principles of Implant Positioning
55
ALWAYS PROSTHETIC DRIVEN
X
X
X

56. Principles of Implant Positioning
56
Four factors must be correctly addressed to achieve both optimal esthetic results
and biologic health.
Vertical
positioning of
implant in the
bone
Buccolingual
positioning of
implant in the
bone
Mesiodistal
placement of
implant in the
bone
Trajectory
or angle of
the implant

57. Vertical positioning of the implant
57
In esthetically demanding situations, implants
must be placed below the crest of gingiva at a
level that respects biologic health and provides
proper emergence profile.
Earlier it was suggested that implant be placed
more than 5 mm below the crest of gingiva but
such placements resulted in the failure of
implant.
But this is no longer acceptable as it led to
frequent perforations on inferior cortical bone.

58. Crown height
58
This affects the appearance of the final
prosthesis.
Affects the amount of moment of force on the
implant and the surrounding crestal bone during
occlusal loading.
It is measured from the occlusal or incisal plane
to the crest of the ridge.

59. Crown height
59
• It’s a vertical cantilever or lever that magnifies any lateral or cantilever forces.
• Greater the crown height ,the greater the moment of the force under lateral loads
• For every 1 mm increase force increase may be up to 20%.
• Crown height increases as the bone height decreases so more number of
implants to be inserted.
• Minimum crown height needed for a fixed implant prosthesis should be 8 mm.
• Crown height space is related directly to the crown height of the prosthesis which
is greater in anterior regions of the mouth.
If too much crown height space is present before placement then  autogenous
or membrane grafts to be used to increase the vertical bone height

60. Available bone height
60
Shorter implants(8mm)
More dense bone
Minimum height of
available is in part
related to density of
available bone.
Less dense and weaker bone
Longer implants(12mm)
• Anterior regions limited between nares and inferior border of the mandible.
• Maxillary canine eminences region offers greatest height of available bone than any
other maxillary anterior sites.
• Greater bone height in max 1st premolar than the 2nd premolar.
• Mandibular premolar anterior to foramen provides greatest vertical column of
bone.

61. Available bone height
61
• Maxillary canine eminences region offers greatest height of available bone than any
other maxillary anterior sites.
• Greater bone height in max 1st premolar than the 2nd premolar.
• Mandibular premolar anterior to foramen provides greatest vertical column of
bone.
• Initial anterior maxillary available bone height is less than the mandibular available
bone height.
• Angle’s class II have shorter mandibular heights.
• Angle’s class III exhibit greatest heights.
• Panoramic radiographs are still the most common method for preliminary
determination of available bone height.

62. Buccolingual positioning
62
Extremely important for placement of implants in crown and bridge restorations
in areas demanding high esthetics.
Must be positioned far enough buccally to provide proper esthetics but it must
not invade or compromise the thin plate of buccal bone.

63. Available bone width
63
• Is measured between the facial and lingual plates at the crest of the potential
implant site.
• Root form implants of 4mm crestal diameter usually require more than 6 mm of
bone width to ensure sufficient bone thickness and blood supply around the
implant.
• These dimensions provide more than 1mm bone on each side of the implant at
the crest.
• Crest of the ridge is supported by wider base which has a triangular cross
section an osteoplasty can provide a greater width although of reduced height
• This is untrue in case of anterior maxilla as edentulous ridge exhibits labial
concavity.
• The ideal implant width for a single tooth replacement or multiple adjacent
implants often is related to “the natural tooth being replaced”

64. Mesiodistal positioning
64
One of the most important factors to be considered while placing implants.
The greater the number of teeth replaced with implants the greater the esthetic
challenge.

65. Rule of 1,2,3 & 7
65
A rule has been suggested to guide in the placement of implants:
01 02 03 07
Bucco- lingually Distance Distance Distance
1 mm of bone is between between between crest
present after tooth and implant and
implant implant in implant in mm
placement mm.
of bone and
opposing tooth.

66. Angulation
of implants

67. Angulation of implants
67
It is generally accepted that implants are best loaded vertically.
This suggests implants should be angled perpendicular to plane of occlusion.
Bone of maxilla and mandible are not always perpendicular to plane of
occlusion especially in mandibular posterior and maxillary anterior regions
Angled abutments to correct angulation off the perpendicular are acceptable.
Forces are tensile, compressive and shearing to the implant system.
Bone is strongest to compressive,30% weak to tensile and 65% weak
to shearing forces.

68. Available bone angulation
68
• Mandibular roots flare so crowns are lingually inclined in posterior regions &
labially inclined in anterior region.
• Alveolar bone angulation represents the root trajectories in relation to occlusal
plane.
• In posterior mandible submandibular fossa mandates implant placement with
increasing Angulation as it progresses distally 15,20,25 degrees and so on.
• The distance from the centre of the most anterior implant to the line joining the
distal aspect of the two most distal implants is called the Anteroposterior or A-P
spread.
• Indicates the amount of cantilever that can be planned.
• As a rule when 5 anterior implants are planned in the anterior mandible for
prosthesis support the cantilevered posterior section of the restoration should
not exceed 2.5 times the A-P spread.

69. Available bone angulation
• T
apering arch form is preferred for anterior implants
supporting posterior cantilevers.
• Square arch form is preferred when canine and posterior
implants are used to support anterior teeth in either arch.
• Modulus of elasticity is proportional to cube of the diameter of
the implant.
• Greater the modulus of elasticity greater will be the
amount of biomechanical mismatch and less likely the bone
would be maintained at the interface.
• This biomechanical mismatch is known as stress shielding.
• Thus larger diameter should be used with caution.
69

70. Missing teeth number & Abutment number
70
In completely edentulous patients,
• No of implants in mandible= 5-9 with at least 4 of these placed between mental
foramen.
• No of implants in the maxilla= 6 to 10 with 2-3 implants placed in the premaxilla
Abutment number
• Overall stress on the implant system can be reduced by increasing the surface
area to which the force is applied.
• This is achieved by increasing the number of implants to support the prosthesis.
Abutment position
• This is also related to implant number as 2 or more implants are needed to form a
biomechanical tripod that is not a straight line.
• Suggested that multiple units be placed in a staggered buccal abutment offset.

71. Missing teeth number & Abutment number
71
In completely edentulous patients,
• No of implants in mandible= 5-9 with at least 4 of these placed between mental
foramen.
• No of implants in the maxilla= 6 to 10 with 2-3 implants placed in the premaxilla
Abutment number
• Overall stress on the implant system can be reduced by increasing the surface
area to which the force is applied.
• This is achieved by increasing the number of implants to support the prosthesis.
Abutment position
• This is also related to implant number as 2 or more implants are needed to form a
biomechanical tripod that is not a straight line.
• Suggested that multiple units be placed in a staggered buccal abutment offset.

72. Implant
design and
Size

73. Implant Design
73
• Implant design may affect surface area more than the increase in the width.
• A cylindrical implant provides 30% less surface area than a conventional
threaded type of implant of the same size.
• Implants with greater surface area should be selected in situations of poor
bone densities and higher stresses.

74. Implant Size
74
• An increase in implant length is beneficial for initial stability and overall amount
of implant bone interface.
• The surface area of each implant is related directly to the width of the implant.
• Wider root form > narrower root form implants.
• 0.25mm increase in implant diameter 5 to10% increase in surface area.
• Greater diameter implants increases the surface area at the crest of the ridge,
where the stresses are highest.

75. Available bone
75
• As a general guideline 2mm of surgical error is maintained between implant and
any adjacent landmark especially when the landmark is mandibular canal.
• Usually the implants have a crest module wider than the body dimension
• Crestal dimension of bone (where the wider crest module dimension is placed) is
usually the narrowest region of the available bone
Implant placement
Incision
Pilot hole - 2– 3mm depth.
Inclination of Bur
Maxillary
Mandibular
- 40-90°.
- 30-45°.
Placed With Minimal Pressure, copious irrigation and intermittent drilling.
50gms – 250 gms of load can be applied immediately.

76. Surgical
Procedure

77. Surgical Procedure
77

78. Flapless Technique
78

79. Flap Raised Technique
Papilla Preserving
Single stroke Incision
79

80. 80

81. 81

82. 82

83. 83

84. 84

85. 85

86. Suturing the flap
86
• The flap is sutured back into place using monofilament suture.
• The anterior papilla should be secured first.
• The vertical release is then sutured, followed by the mesial and distal sides of
the abutment.
• These are routine interrupted sutures tied in the same fashion as the first
suture described

87. Post operative Instructions
87
Dietary Instructions
Antibiotics Analgesics
Oral hygiene instructions

88. Recent
Advances

89. Osseo
densification
• A new method of biomechanical bone
preparation
• Densah burs are used
• Bone preservation and condensation
• OD does not excavate bone
Implant placement
89

90. • Root is bisected.
• Buccal 2/3rd of root is preserved in the socket
• Periodontium along with bundle bone remain intact.
• Buccal bone remains intact
Socket shield
90

91. Platform switching
• Use of smaller diameter abutment on a larger
diameter implant collar
• Preserves crestal bone
91

92. • Peek
• Trinia
• Biohpp
• Shape memory niti implant
92
Implant materials

93. Peek
• Fewer hypersensitive and allergic reactions
• Radiolucent,causes few artifacts in MRI.
• Doesnot have a metallic color(beige color)-more
aesthetic apperaence
• Used as implant body,abutment and superstructure
• CFR peek ,GFR peek.
93

94. Trinia
• CAD/CAM reinforced polymer
• Used for core in non-metallic prosthetic restorations
,including implant super structure.
• Light weight
• No firing required
• Biocompatible .
94

95. • PEEK variant
• Ceramic filler is added in this material
• Metal free
• No abrasive for remaining teeth
• Can be veneered with traditional composites
• No discoloration
• High esthetics.
95
BIOHPP

96. • X PEED-Megagen system
96
Surface coatings

97. Shape memory abutments
97

98. Customized 3d printed implants
98

99. All On Four
• TTPHIL-ALL TILT(Tall Tilted Pin Hole Immediate Loading
• Bicortical engagement of implants
• Less stress on the bone with reduced chances of bone
resorption
• No cantileverage
• T
all (16-25mm) tilted (30°-45°).-tall implants more
surface area for osseointegration
• Implants placed in pinhole manner ie,flapless
99

100. Zygomatic ,Basal, Pterygoid Implants
100