A must read seminar on Dental Implants for Under-Graduates and Post-Graduates. If you have any doubts regarding Dental Implants or any topic if you are unable to understand then do feel free to contact me on my Email address: Dr.anujparihar@gmail.com

3. Dental Implants
Definition - A Dental Implant is
defined as “ A substance that is placed into
the jaw to support a crown or fixed or
removable denture.”

6. Indications:
• For completely edentulous patients with
advanced residual ridge resorption.
• For partially edentulous arches where RPD
may weaken the abutment teeth.
• In patients with maxillofacial deformities’.

7. • For single tooth replacement where fixed
partial dentures cannot be placed .
• Patients who are unable to wear RPD.
• Patients desire .
• Patients who have adequate bone for the
placement of implants.

8. • CONTRAINDICATION
• Presence of non treated or unsuccessfully
treated periodontal disease
• Poor oral hygiene.
• Uncontrolled diabetes.
• Chronic steroid therapy .
• High dose irradiation.
• Smoking and alcohol abuse.

9. • ADVANTAGES-
• Preservation of bone
• Improved function
• Aesthetics
• Stability and support.
• Comfort.

10. • Disadvantages-
• Can not be used in medically compromised
patients who cannot undergo surgery.
• Longer duration of treatment.
• Need of a lot of patients cooperation
• Very much expensive.

11. CLASSIFICATION
(A) Depending on the placement with in the
tissue.
• Epiosteal implants- These implants receive their
primary bone support by resting on it.
eg- Sub-periosteal implants.
• Transosteal Implants- These implants penetrate
both cortical plates and passes through the entire
thickness of alveolar bone.

12. • Endosteal implants-
This kind of implants
extends into basal bone for support.
(B) Depending on materials used .
• Metallic Implants-
Ti
Ti alloy
micro enhanced pure Ti
plasma sprayed Ti
Co,Cr,Mo alloy

16. Non metallic Implants-
Ceramic
Carbon
Alumina
Polymer
Composite
(C) Depending on Design
Screw shaped
Cylinder shaped
Tapered screw shaped.

17. PARTS OF IMPLANT
1.Implant body
It is the component that is placed with in the bone during
first stage of surgery
• Threaded
• Non threaded
2.Healing screw
:During the healing phase this screw is
normally placed in the superior surface of body
Function: Facilitates the suturing soft tissues.
Prevents the growth of the tissue over the edge
of the implant.

18. 3. Healing caps:
are dome shaped screws placed
over the sealing screw after the second
stage of surgery & before insertion of
prosthesis.
4.Abutments:
part of implant which resembles a
prepared tooth & is inserted to be screwed
into the implant body
5. Impression posts

20. IDEAL REQUIESETS
to achieve an osseointigrated dental implant with a
high degree of predictibility the implant must be-
• Sterile
• made of a highly biocompatible material
• Inserted with an atraumatic surgical techinique that
avoids overheating of the bone.
• Placed with initial stability
• Not functionally loaded during the healing period

21. PERIMPLANT MUCOSA
Mucosal tissues around intraosseous
implants form a tightly adherent band
consisting of a dense collagenous lamina
propria covered by stratified squamous
keratinised epithelium.
Implant epithelium junction is
analogous to the junctional epithelium around
the natural teeth in that the epithelial cells
attach to the titanium implant by means of
hemidesmosomes and a basal lamina.

22. •
The depth of normal noninflammed sulcus
around an intraosseous implant is assumed to
be between 1.5-2mm.
• The sulcus around an implant is lined with
sulcular epithelium that is continuous apically
with the junctional epithelium.

23. Main difference between periimplant &
periodontal tissues is that
1. Collagen fibers are non attached & run
parallel to the implant surfaces owing to the
lack of cementum.
2. Marginal portion of the perimplant mucosa
contains significantly more collagen & fewer
fibroblasts than the normal gingiva.

24. THE IMPLANT-BONE INTERFACE
The relationship between endosseous implants &
the bone consists of two mechanisms-
1.OSSEOINTEGRATION-
bone is in intimate but not ultrastructural contact
with the implant.
2.FIBROSSEOUS INTEGRATION-
soft tissue such as fibers &/or cells, are interposed
between the two surfaces.

27. GENERAL PRINCIPLES OF IMPLANT SURGEY
PATIENT PREPRATION
Most implant surgical procedures can be done in the office using
local anaesthesia. For some patients, depending on individual
preferences and complexity of the case, conscience sedation may
be indicated.

28. IMPLANT SITE PREPARATION
BASIC PRINCIPLES OF IMPLANT THEREPY TO ACHIEVE
OSSEOINTEGRATION
1. Implants must be sterile and made of a biocompatible material.
2. Implant site prepration must be performed under sterile
conditions.
3. Implant site preparation must be completed with an atraumatic
technique that avoids overheating of the bone during preparation
of the recipient site.
4. Implants should be placed with good initial stability.
5. Implants should be allowed to heal without loading or
micromovements for 2 to 4 and 4 to 6 months in mandible and
maxilla respectively.

29. ONE STAGE VERSUS TWO STAGE IMPLANT SURGERY
In the one stage approach the implant or the abutment emerges
through the mucoperiosteum at the time of the implant
placement, whereas in the two stage approach the
the top of the implant and the cover screw are completely
covered with the flap closure.
ONE STAGE IMPLANT TWO STAGE IMPLANT

30. The advantage of the one stage surgical stage includes easier
mucogingival management around the implant. Patient
management is also simple as a second stage surgery is not
required.
The two stage surgery is advantageous in cases where
simultaneous ridge augmentation is required.
This approach also prevents movement by the patient who may
inadvertently chew on it during healing period.

31. INSTRUMENTS
Dissector : Used to mark proposed incision as a line on
mucosal tissues

32. Screwdrivers : Short, long, hexagonal type of screwdrivers are
available.

33. Fixture mount: used in placement of individual fixtures to help
avoid contamination with other metal surfaces.

34. Fixture: Available in two diameters -3.74 & 4mm. Each one is
available in different lengths like 7, 10, 13, 15, 18 & 20 mm. Fixtures
are placed in titanium cylinder sealed in glass ampules. They are
handled by titanium instruments only.

35. Cylinder wrench: Wrench that fits on top of fixture mount & used
to tighten fixture after placement.

36. Spiral drill (or round bur): Round shaped drill used to mark fixture
site by making initial entry into cortical bone. It is used to penetrate
only through superior cortical plate.

37. Twist drill (2 mm): Has 2 mm diameter & is available in different
lengths, 7,10,15,20 mm.

38. Pilot drill : Used after using 2 mm twist drill to enlarge fixture
site 2 to 3 mm . Due to this, use of 3 mm twist drill becomes easier.

39. Twist drill (3mm) : Used after pilot drills to enlarge fixture site.

40. Countersink drill : Used after twist drill to enlarge coronal portion
of fixture site. By countersinking, fixture & cover screw are
positioned level with crestal bone level.

41. Abutment : It is made of titanium & is available in following
sizes – 3, 4, 5.5, 7, 8.5, 10 mm in length. Each abutment cylinder
size has a corresponding abutment screw for use with that
particular size.

42. Direction indicator: Double ended instrument used to check
parallelism during drilling procedures.

43. Depth gauge : Graduated end is used to measure depth of fixture
sites & opposite end to measure distance between adjacent fixture
sites.

44. Cover screws : To cover fixture after installation

45. Healing cap (gingival former): Made of plastic material that fits
intothreads of abutment screw. Used to mould the gingiva around
the implant.

46. Abutment: It is made of titanium & is available in following
sizes – 3, 4, 5.5, 7, 8.5, 10 mm in length. Each abutment cylinder
size has a corresponding abutment screw for use with that
particular size.

47. IMPLANT SURGICAL PROCEDURE
Can be be performed in 2 ways-
1. Two stage implant surgical procedure- 1st for implant insertion
2nd for uncovering implant
2. One stage implant surgical procedure- - implant inserted & left
exposed to oral environment

48. FLAP DESIGN AND ELEVATION
INCISIONS
• Crestal incision:Is the preferred incision as less bleeding, edema,
ecchymosis,less vestibular changes, faster healing, easier to manage.

49. 2. REMOTE INCISION
Usually 1-2 mm inferior to mucogingival junction.
Advantages:
Covering implant without sutures on its top.
Incision of choice when extensive bone augmentation
is required.

50. A guide drill is used to mark proposed fixture sites & penetrate the
cortical plate . splint can be used to locate fixture site.
Use of 2 mm twist drill : to enlarge fixture site.
Site closest to midline is prepared first & a direction indicator inserted.
Then prepare most distal site maintaining parallelism.

51. Threshold Level For Osteocyte Damage lies around 47 0C
i.e. only 10 0C above body temp. If temp. of bone exceeds
47 0C for 1 min. bone resorption & fat cell degeneration
occurs. This results in loss of bones ability to regenerate
& repair itself. Heat injured bone is replaced by less
differentiated bone which may result in fibrous
encapsulation.
-Use intermittent drilling technique
-Sharp burs
-Profuse chilled saline irrigation
-Sequence of preparation steps
-Speed – 800 to 1000 rpm
PRECAUTIONS IN BONE DRILLING

52. Place direction indicators into all prepared sites, then use pilot
drill to enlarge site from 2 – 3 mm.

53. After pilot drilling is finished, fixture site is enlarged with a 3 mm
twist drill.

54. Countersink procedure is done to achieve a fixture & cover
screw height level with alveolar bone.

55. TAPPING PROCEDURE(OPTIONAL)
Tapping is procedure of creating threads into fixture site.
It is done with low speed handpiece & screw tap to avoid heat
generation in bone.

56. IMPLANT PLACEMENT
Implants are placed with a handpiece working at slow speed or by hand
with a wrench.
Insertion must follow the same path as the osteotomy site.
When multiple implants are being placed it is helpful to use
guidepins in the other sites to have a visual guide for the path
of insertion.

57. Cover screws are positioned on fixtures & threads are engaged.
Surgical site is thoroughly cleaned & bony sharp edges removed

58. FLAP CLOSURE AND SUTURING
One of the most imp. aspect of flap management is primary
closure that is tension free.
A combination of alternating horizontal matress and interrupted suture.
It is simpler to use a resorbable suture that does not requires removal
during the post operative healing phase.
But when moderate to severe post operative sweling is anticipated a
non resorbable suture is recommended to maintain a longer closure
period.

59. POST OPERATIVE CARE
Simple implant surgery in a healthy patient does not requires
antibiotics.
However the patient can be premedicated with antibiotics starting
one hour before the procedure and continued 1 week if the
surgery is extensive or it requires bone augmentation.
CHX mouthrinse should be prescribed
Adequate medication should be prescribed for pain control.
Soft diet for the first few days.
Refrain from tobacco or alcohol for 1 to 2 weeks post operatively.

60. SECOND STAGE EXPOSURE SURGERY
For implants placed using the two stage submerged protocol, a
second stage exposure surgery is necessary after the
prescribed healing period.
OBJECTIVES OF SECOND STAGE IMPLANT SURGERY
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 keratinised tissue around the
implant.
4. To facilitate oral hygiene.
5. To ensure proper abutment seating.

61. A healing period of 3 months in mandible & 6 months in maxilla is
required before 2nd stage surgery.
Radiographic interpretation of fixture to bone anchorage can be
done.
When radiopacity is observed & bone growth appears around
cover screws, second stage surgery can be performed immediately.
Implant mobility is an important criterion & fixture should be
removed if it’s mobile.

62. Performed under local anesthesia.
Surgical splint can be used to locate fixtures.
When a cover screw is located, cut tissues circumferentially to
it.
Hexagonal screwdriver is used for maxillary cover screw, slot
shaped screw driver for mandibular cover screw.

63. The head of the implant is thoroughly cleaned of any soft or hard
tissue overgrowth.
Depth gauge is used to measure depth of tissues between fixture
head & gingival margin.
The healing abutment is placed on the implant.
The fit of the implant to the healing abutment is evaluated and
confirmed by an IOPA, to check for complete seating.

64. POPST OPERATIVE CARE
Good oral hygiene.
CHX rinses.
Fabrication of superstructure can begin in 2-4 weeks.

65. These implants don’t remain submerged after being inserted &
therefore do not require second (uncovering) operation.
-Fixture protrudes about 2-3mm from bone crest.
-In two stage technique, implant is placed flush with bone crest.
Hence, flap management for this system is different from two
stage implant.
ONE STAGE NON SUBMERGED IMPLANT PLACEMENT

66. Flap is kept thin in one stage implant & placed apical to future
margin of prosthesis.
Soft tissue is purposely kept thick in two stage implant.
In one stage implant, flap design is always a crestal incision
bisecting existing keratinized tissue.
The implant site site prepration is similar to two stage
procedure. The primary difference is that the implant or the
healing abutment is placed in such a way that the head of the
implant protrudes about 2 to 3 mm from the bone crest.

67. POST OPERATIVE CARE
Similar to the two stage approach exept the fact that the cover
screw or the healing abutment is exposed to the oral
environment.
Patients are advised to avoid chewing in the area of the implant.
Prosthetic appliance are not to be used if chewing forces are
transmitted tio the implant especially in the early healing
period.

68. CONCLUSION
It is essential to understand and follow basic guidelines to
achieve oeeeointegration predictably.
Fundamental protocols must be followed for implant
placement.
These fundamentals apply to all implant systems.