Raju introduction of implants /orthodontic courses by Indian dental academy

Introduction
of implants
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

contents
Introduction
Implant components
Classification of implants
Implant Surface coatings
Implant Abutments
Implant Attachments
Conclusion
References

INTRODUCTION
Loss of teeth, eventual edentulism, and wearing of complete
dentures have been part of expected course of aging by general
population.
Incidence of edentulism in western world has posed
challenge to Prosthodontists & Oral surgeons, encouraging them
to devise acceptable prosthetic results for patients.

Components of implant
Implant body

Cover screw Healing abutment

Implant abutment is the intermediate connector between the
implant and the restoration, it may extend above the tissue. In
some instances is subgingival, to provide a more esthetic
restoration.
Implant abutment

Impression posts

Laboratory analogs

Classification of implants

BASED UPON THE PLACEMENT WITHIN THE TISSUE
Mucosal inserts

Subperiosteal implants

Endosteal implant

Root form Blade/plate form
Ramus frame

Transosteal implant

Endodontic stabilizer implant

Based upon materials used
1.Metallic implants- Commercially pure titanium
Titanium alloy
Cobalt chromium molybdenum
2.Nonmetallic implants- Ceramics
Carbon

Based upon the attachment mechanism
1.Osseointegration
2.Fibro osseous
integration

Based upon their surface coating
1. Titanium plasma sprayed
2. Hydroxyapatite coating
3. Grid blasting with TiO
4. SLA(sandblasted-largegrid-acidetched)
5. Acid etched
6. Machined surface

Cylindrical Screw shaped implants.
Threaded Non threaded.
Based on shape

Based upon the surgical stage
Two stage implants One stage implant

Based upon tissue response
o Biotolerant materials-polymethylmethacrylate
o Bioinert materials-titanium and aluminium
oxide
o Bioactive materials-glass and calcium phosphate ceramic

IMPLANT SURFACE
CHARACTERISTICS

Non threaded
•Tendency for slippage
•Bonding is required
•No slippage tendency
•No bonding is required
Threaded

Threaded implants :
Alteration in the design, size and pitch of
the threads can influence the long term
osseointegration.
Advantages of threaded implants
More functional area for stress load
distribution than the cylindrical implants.
Threads improves the primary implant
stability avoids micromovement of the
implants till osseointegration is achieved.

Roughness parameter (Sa)
0.04 –0.4 µm - smooth
0.5 – 1.0 µm – minimally rough
1.0 –2.0 µm – moderately rough
> 2.0 µm – rough

Weinerberg – moderately rough implants developed
the best bone fixation
In vivo studies
Smooth surface < 0.2 µm will – soft tissue →no
bone cell adhesion → clinical failure.
Moderately rough surface more bone in contact
with implant → better osseointegration.

Advantages of moderately rough surface :
Retention of the fibrin clot, osteoconductive scaffold,
osteoprogenitor cell migration and faster osseointegration.
Increase rate and extent of bone accumulation → contact
osteogenesis
Increased surface area renders greater osteoblastic proliferation,
differentiation of surface adherent cells.
Increased cell attachment growth and differentiation.
Increased rough surfaces :
Increased risk of periimplantitis
Increased risk of ionic leakage / corrosion

TITANIUM
10 A in milliseconds
100 A in minute
2000 A in 6 years

Additive surface treatment :
Titanium plasma spraying (TPS) hydroxyapatite (HA) coating
Substractive surface treatment :
Blasting with titanium oxide / aluminum oxide and acid etching
Modified surface treatment :
Oxidized surface treatment
Laser treatment
Ion implantation

Machined / turned surface
SEM x 1000 SEM x 4700
Cp Titanium
Surface roughness profile 5 µm

Titanium plasma sprayed coating (TPS)
6-10 times increase surface
area.
Roughness Depth profile of about 15µm
15000-20000 degrees c
3000 m/ sec

Hydroxyapatite coatings
HA coated implant bioactive
surface structure – more rapid
osseous healing comparison
with smooth surface implant.
↓
Increased initial stability
SEM 100X
HA coatings often exhibit cracks or even
complete loss of HA coating and heavier
colonisation of microorganisms

Sand blasting large grid Acid etching ( SLA )
Sand blasting – surface roughness
(substractive method)
Acid etching – cleaning
SEM 1000X SEM 7000X
Decrease in contact angle by 100
–
better cell attachment.
Acid etching with 1% HF and 30%
NO3 after sand blasting – increase in
osseointegration by removal of
aluminium particles (cleaning).
Wennerberg et al superior bone fixation and bone adaptation

Laser induced surface roughening
Eximer laser – “Used to create roughness”
Regularly oriented surface roughness configuration compared
to TPS coating and sandblasting. Physiologically mimic
natural trabecular bone
SEM x 300
SEM x 300SEM x 70

The clinical advantages of coatings:-
1. Increased surface area.
2. Increased roughness for initial stability.
3. Stronger bone to implant interface.

DISADVANTAGES OF COATINGS:-
1. Flaking, cracking, or scaling upon insertion.
2. Increased plaque retention above bone.
3. Increased bacteria and nidus for infection.
4. Complication of treatment of failing implants
5. Increased cost.

Implant
abutments

ABUTMENT
Portion of implant that supports and
retains a prosthesis or implant
super structure
Abutment consists of 3 constituents
which may be unified or separate
1. Base – fits into antirotational
component
2. Head – protrudes permucosally
and serve as prosthetic retainer
3. Retaining screw – which affixes
to implant

ABUTMENT
TYPES
 Depending upon retention
1. Abutment for screw retention
2. Abutment for cement retention
3. Abutment for attachment
 Depending upon angulation
1. Straight abutment
2. Angled abutment

Depending upon design
1. Flat topped abutment
2. Tapered shouldered abutment
3. Direct gold copings
Commercially available
1. Ceraone abutment
2. Ceradapt abutment
3. UCLA abutment
4. Noble bio care abutment
5. Estheticone abutment
6. Noble pharma single tooth abutment
7. Astra abutment

ABUTMENT RETENTION
Retention– resist removal of the retainer along the path of
insertion
Resistance – opposes movement of the abutment under
occlusal loads and prevents removal of restoration by
forces in apical and oblique direction

Abutment taper
Retention decreases as the taper is increased from 6-25 degrees
• Ideal taper is 2-5 degrees
• Parallelism of axial walls has been recognized to be single most factor
for retention
• Eames et al – found that clinically acceptable preparations present a
taper of 20 degrees

Abutment surface area
There is linear increase in retention as the
diameter increase for preparation with
identical height

Abutment height
A tall preparation offers greater retention than a short
abutment
Increase in height – increases surface area , increased
resistance to lateral forces
Height of the abutment must be greater than the arc of
rotation
Arc of rotation decreases when grooves are prepared in
abutment

 Abutment surface roughness
1. Surface roughness increases the retention
of a restoration by creating micro retentive
irregularities into which the luting agent
projects
2. Surface roughness retention is dependent
upon the type of burs and the thickness of
luting agents
3. Internal aspect of the casting should be air
abraded with 50 micro meter alumina to
enhance retention by 64%

Path of insertion

NON PARALLEL ABUTMENTS
Angle less than 20 degrees

Anti rotational features of implant systems
Anti rotational features on implant inhibit unwanted
movement of their overlying abutments. Anti rotational
components in current use include
External hex,
Internal hex,
Spline type interface,
Morse taper

Antirotational features of abutments
External hex
 Most widely available
 Found on top of abutments
 Hexagonal geometry
Internal hex
 Provides more precise implant
abutment interface
 Seats the abutment into hexagonal
depression

SPLINE ATTACHMENT
Splines are fin to groove anti rotational design
Consist of six external components called tines which
protrude 1mm from implant and are matched to a female
embedded in a abutment base

MORSE TAPER ATTACHMENT
 Consist of 1 piece abutment post with 5 degree taper
 Resist rotation and even removal
 Also referred to as cold welded design

Guidelines for abutment selection
Depth of soft tissue
 Measured with periodontal
measuring probe
 labial margin of abutment is
atleast 1mm subgingival
 Diameter close to that of
cervical margin of tooth

Emergence profile
 Need atleast 3mm of vertical space from implant head to
gingival margin
 Allows gradual transition from implant head

Orientation
 Ideally implant is placed close to the long axis of missing
tooth.
 Small degree of labial angulation – easily accomodated
with standared abutments
 If more labial angulation needed – use of standard
abutment leads to
1. Excessively contoured labial surface
2. Porcelain surface too thin to mask metal structure

Interocclusal space
 Space from implant head to opposing tooth
 Vertical space of 6-7 mm – standard abutment
 5mm of space – preparable abutment
 Less than 5mm of space – vertical dimension of occlusion
increased, deeper implant placement

CEMENT RETAINED ABUTMENTS
1. superstructures are more passive
2. Easier to obtain esthetics
3. Fewer porcelain fractures
4. Common procedure and economical
5. Manipulation in posterior region is easier with cement
6. Loosen less often compared to that of screws
7. Progressive loading
8. Less fatigue
9. Abutment-crown crevice
10. cost

Disadvantages
1. When permanent cements are used evaluation and
maintainence of implants is difficult
2. Difficult to retrieve unless soft cements are used
3. Temporary cements wash out prematurely
4. Greater abutment height required
5. Less resistance to tensile forces

Types of abutment for cement
retention
1.Single unit or one piece abutment
2 .Two piece abutment
1.Single unit or one piece abutment
does not engage anti rotational hex
but fits flush with the implant
platform
2 . Two piece abutment
has one component to engage anti
rotational hex of implant body and
other component to fixate the
abutment and implant body together

SCREW RETAINED ABUTMENTS
1. Low profile of retention
2. Reliable security when mesostructure bars of of limited
vertical dimension are used
3. Space for denture teeth
4. No risk of cement in the sulcus
5. Easily retrievable

FACTORS THAT AFFECT SCREW CONNECTION
1. misfit
2. poor abutment screw tightening
3. excessive occlusal loading
4. inadequate screw design
Misfit has been reported to be as high as
1. 66 micrometer between implant and abutment in
vertical direction ,
2. 99 Micrometer in horizontal dimension

Abutment for attachment
• Uses an attachment device to retain a removable prosthesis
• Includes
Mesostructure bars – continuous and non continuous
Super structure attachments – magnets ,, hader clips of plastic or
gold , zest anchors ,o - rings , ERA attachments.

STRAIGHT ABUTMENT
 Indicated for replacing single tooth for
large prosthesis upto full arch.
 Used only when emergence profile are
parallel
 If abutments are not parallel – can be
prepared by
1. Direct method
2. Indirect method

ANGLED ABUTMENT
1. Available in angulations from 10-30
degrees
2. Improved esthetics
3. To correct path of insertion
4. Increase in angle – increase risk of
fracture
5. Difficult to manipulate
6. Multiple small parts increase
possibility of component looseening

ABUTMENT DESIGNS
FLAT TOPPED ABUTMENT
Used to support bars for overdentures/ fixed detachable hybrid
prosthesis
Do not engage antirotational component
advantage – simplicity
disadvantage - does not have counter rotational forces-
unsuitable for single tooth replacement
Straight emergence profile- unesthetic in anterior maxilla

TAPERED SHOULDERED ABUTMENT
Indicated in – bars to overdentures, hybrid overdentures,
single tooth replacement
Tapered design-resistance to lateral forces is enhanced
Lower profile abutment collars- subgingival margin –
esthetic
Tapered shoulder- angled at 9-15 degree thus allowing
divergence between implants 18-30 degrees

DIRECT GOLD COPING
Coping bypass abutment entirely
Consists of two parts- coping and screw
Porcelain is baked directly on to coping – results in crown
which attaches directly to implant body
Coping engages antirotational component of implant
Indications
1. Single tooth restorations
2. Limited interocclusal space
3. Where subgingival margins are required

CERAONE ABUTMENT
• CeraOne abutment is designed to
accept a cementable ceramic core
restoration
• The most frequently used
abutment for single tooth
restorations is the CeraOne
abutment.
• Clinicians have found that these
abutments yield good esthetic
results and have safe, fast and
easy handling.
• Abutment available in 5 heights
– 1,2,3,4,5 mm

Ceramic cap –available in cylindrical
form for posterior arch and tapered
form for anterior arch that fits over
ceraone abutment
Cap- made up of densely sintered
semi translucent aluminium oxide
which is designed to be fused with
porcelain and cemented
permanently to abutment

 In posterior areas- ceraone
abutment is used with
ceramometal coping
 Since esthetics may not be critical
in posterior areas, plastic wax up
coping is used to fabricate
ceramometal coping with or
without access channel to which
porcelain is fused
 To facilitate during
troubleshooting , a lingual
removal button is designed
 A narrow occlusal access channel
can also be fabricated in gold to
facilitate reentry

ESTHETICONE ABUTMENT
 Noble biocare abutment
 hex shaped,tapered sides
 features a female hex which
interface with implant male hex
head and is secured by a titanium
abutment screw

 Indicated in multiple implant
situation without causing
esthetic compromise with the
metal display
 Designed to allow esthetic
veneering material to be
placed subgingivally
 Abutment available in 1,2,3
mm collars

CERADAPT ABUTMENT
 All ceramic alternative to metal
abutments
 Pre machined precision milled
abutment made to fit the implant
hex
 made up of densely sintered
99.8% pure aluminium oxide
which are pressed into desired
shape and subjected to sintering
temperature of 2050 degrees
Celsius
 pore free strong wear resistant
stable bio ceramic material

 A great advantage of the CerAdapt abutment is that it allows a
better emergence profile, because it is wider in its cervical
portion, and it also enables the differentiation in the gingival
finish line of the preparation.
 This line accompanies the concave arch of the marginal
gingiva, differentiating the heights of the mesial and distal
regions

 Andersson and Oden showed
flexural strength of 690 MPA and
demonstrated that the abutment can
withstand tremendous loads without
fracturing
 It is a non metallic , non corrosive ,
bio compatible. soft tissue response
is excellent
 Tooth colored and light diffusion
property – more natural and esthetic
implant crown
 Used for implant supported single
and multiple tooth restoration in the
anterior canine and premolar regions
 Can be either screw or cement
retained

UCLA ABUTMENT
 Most adaptable and versatile
abutment for very restricted
working area
 Improved esthetics
 Abutment can be custom
reangulated
 All abutment have a non rotating
configuration
 Improved emergence profile

 Each restoration has a tapered interface similar to that of a
standard FPD restoration
 Multiple butt joint prosthesis interface avoided
 Lingual screw retention for fixed retrievability - practical
and esthetic

CUSTOM REANGULATED UCLA ABUTMENT
 Eliminates need for prefabricated angled abutment
 Simplifies construction
 Results in better esthetics
 When implants are not parallel , parallelism can be
obtained

 Secured with titanium abutment screw
 Pre machined internal hex interfaces with implant male
hex provides maximum resistance to lateral forces and
screw loosening
 Lingual surface of abutment is tapped to receive a gold
screw – fixed retrievabiltiy

BRANEMARK SYSTEM SINGLE TOOTH
ABUTMENT
 Developed by Noble pharma
 Designed to adjust access hole
position,prosthetic screw angulation
 Improved esthetics

ASTRA ABUTMENT
• Presented with the option of 20 or 40 degree tapered top
• Used for fixed bridges / over dentures

Computer generated Procera abutment
• Custom abutment-designed by a computer and machined to
exact specification
• Head of implant impression made and working model is
placed in the scanner
• Readings of implant angulation and position are taken
Using cad-cam software,ideal abutment is generated
• Advantages
 Precise fit
 Ideal emergence profile
 Improved esthetics
 Proper restoration contours

• The computer-assisted design system uses a die scanner and a
computer, which converts the digital information obtained by
scanner into a three dimensional image.
• This image reproduces, with high fidelity, the contours of the
dental preparation on a computer screen.
• After the data is processed it is possible, by using a specific
software, to manipulate this preparation, defining the margins,
establishing uniform coping thickness, emergence profile, and
internal space thickness for the cementing agent and other
details.
• The data is sent via modem to coping manufacturing facility.

Abutment try-in kit
 Provide replicas of abutment types that can greatly assist
abutment selection
 Tried intraorally or on a cast
 Made up of aluminium – not damage the implant
 Color coded for easy recognition
 Used for better screw access position ,marginal height and
emergence

Removal of a fractured implant abutment screw
Implant repair kit :
a. Center bit
b. 1.3mm twist drill
c. 1.9 mm twist drill
d. Conical instrument to retrieve the fragment
e. Manual tapping instrument

Implant
attachments

Many edentulous patients experience problems with their dentures,
especially lack of stability and retention, together with a decrease of
chewing ability.
one possibilty of solving this problem is the use of endosseous
implants to which an overdenture can be attached.

The overdenture approach facilitates the fabrication of different
types of prostheses depending on the number of implants
placed. They are
• Implant-supported fixed screw-retained prosthesis
• Implant-supported removable overdenture
• Combined implant-retained and soft tissue-supported
overdenture prosthesis

Definition of attachment
A mechanical device for the fixation, retention, and
stabilization of a prosthesis

Attachments used to retain overentures
• Ball attachments
• O – ring
• ERA attahcment system
• Spheroflex
• Locator attachment system
• ZAAG attachment system
• Bars
• Dolder bar
• Hader EDS bar
• Hybrid bar system
• Resilient
• Rigid

The decision as to what type of overdenture is given is
determined by the following
1. Patients expectations
2. Financial considerations
3. Anatomic and morphologic condition of the bone
4. Shape of the alveolar ridge

Attachment selection based on number of implants and choice of
prosthesis

Categorization of potential implant site in mandible –
By Carl E Misch

Option One
• Supported by free standing
implants in the B and D
position.
• Implants are independent
and not splinted

• Indications
• Indicated when cost is the significant factor
• Anatomical conditions are good
• Ideal anterior and posterior ridge forms
• When patients needs and desires are minimal

• Most common type of attachment used is a Ball, ring type
attachment. Eg: - O-Ring
ERA attachment
Spheroflex

O – ring attachment
• They are doughnut shaped,
synthetic polymer objects
that posses the ability to
bend with resistance and
then return back to their
original shape.
• The O-ring attaches to a
post with a groove or
undercut area.

advantages
• Ease in changing the attachment
• Wide range of movement
• Low cost
• Different degrees of retention
• Elimination of time and cost

ERA attachment
• Resilient precision overdenture
attachment
• Universal hinge with vertical
movement
• Metal jacket which holds the male
attachments

• Four angles to accommodate
divergent implants (0, 5, 11,
17 degrees)
• Two types standard and
micro. Selected based on
interocclusal distance.

Spheroflex
The Sphero Flex is a self paralleling combination titanium
implant abutment and ball attachment. It is the ball attachment
of choice for all implants.

Spheroflex
Self paralleling Implant
abutment overdenture
system with 2.5mm sphere.
Free rotation of 7.5º for one
abutment, 15º degrees for
more than one.

Loactor Implant attachments
Supraradicular design which
comes in a straight abutment
2 angle connections of 10 and
20 degrees for angled
abutments.
Total height is 3.5 mm

• The Self-Aligning feature of the
LOCATOR attachment allows a
patient to easily seat their
overdenture
• Different retentive males that
allow for choice of retention
according to need of patient

Indicated when
1. Interocclusal height is deficient

• Locator female component
on implant
• Male component placed on
the female component

Zaag attachment systems
• In 1972 Zest anchor was introduced to the dental profession.
Initially used as an attachment for overdentures on natural
teeth.
• Later modified as ZAAG(Zest Anchor Advanced Generation)
• Allows upto 15 degees of divergence in female orientation

components
• ZAAG implant abutment of
different heights (3, 4, 5,
6mm). Female matrix of the
system
• Male retentive element
which will seat into the
female matrix

Female abutments in place
Male retentive part seated
Male retentive part placed
and cured in the denture
base

Option two
Implants are positioned in
location B and D and
splinted together with a bar.
Indications:
• patients needs and desires
are minimal
• Patient can afford new
prosthesis and connecting
bar
• Anatomical conditions are
good
• Posterior ridge form is
inverted u shape

Hader bar
• Developed by Hemet Hader
in the late 1960’s.
• Modified by Staubli to EDS
Hader system. Height of the
EDS hader bar is 3 mm.

Plastic form of Hader bar Retentive clip placed on cast bar
Retentive clip being inserted
into denture base

Option three
• Three root form implants
are used. The superstructure
connects the three implants
• Usually the first option
• Patient expectations are
slightly high
• Anatomical conditions are
good
• Cost is not a major factor

• If posterior ridge form is
good , implants are placed
on A, C, E
• if posterior ridge is poor,
implants placed in B, C, D
regions.

Option four (Resilient Hybrid bar design)
Four implants are placed in
A, B, D and E position.
Indications
• Poor posterior anatomy
• Lack of retention and
stability
• Soft tissue abrasion
• Speech difficulties
• Very high patient
expectations

• Attachments placed in the distal cantilever end and the
midline.
• Anterior attachment must allow prosthesis to lift from the bar
to permit rotation of distal attachments.

Indicated in patients who have
1. Poor posterior anatomy
2. Attachment placed in the anterior section is a clip and in the
distal cantilever ball type attachments might be placed.
3. Patient benefits because there is greater vertical support and
lateral stability.

Zaag low profile bar attachment
ZAAG female part placed directly
on the abutment
Male retentive element placed on
the denture base

Loactor bar attachment
• Four evenly placed Locator
female attachment cast on
superstructure in
overdenture option - four

• Four to six retentive
elements are included in the
bar design. Attachments
usally used are Hader clips,
O – ring, ERA.
• Typically four attachments
are placed evenly. Two
anterior and two posterior.

Option five (Rigid Hybrid bar design)
• Five implants are placed in
(A, B, C, D, E).

Indications
Inability to wear conventional dentures
Very high expectations
Unfavourable anatomy
Problems with function and stability
Posterior sore spots

Magnetic attachments ( jackson and shiner magnets )

Advantages:
1. Simplicity of use
2. Low cost
3. Coercivity ( magnetism that does not fade away with time )
Disadvantages:
1. Corrode when contact with oral fluids
2. Permanent discoloration of denture base

REFERENCES
1. Atlas of oral implantology – A.Norman Cranin
2. Contemporary implant dentistry – Carl.E.misch
3. Implants in clinical dentistry – Richard.M.Palmer
4. Implant prosthodontics – Stevens Friedrickson
5. Dental implants fundamental and advanced lab technology –
Winkelman
6. Atlas of tooth and implant supported prosthodontics –
Lawrence.A.Weinberg
7. color atlas of implantology – hubertus spiekerman

8. A positioning jig to verify the accuracy of implant abutments
J prosthet dent 2002; 87; 115.
9. A locating splint for placing implant abutments.
J prosthtet dent 2004; 91; 97.
10. Removal of a fractured implant abutment screw.
11. Do healing abutments influence the outcome of implant
treatment
12. All ceram crowns for single replacement implant abutments
J prosthet dent 1997; 78; 486

Raju introduction of implants /orthodontic courses by Indian dental academy

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