Introduction to Dental implant

Lecturer of prosthetic dentistry and implantology

Faculty of dentistry – Minia University

What is Dental implant ?

A prosthetic device made of alloplastic material(s),

implanted into the oral tissues beneath the mucosal

or/and periosteal layer, and on/or within the bone to

provide retention and support for a fixed or

removable dental prosthesis

(THE GLOSSARY OF PROSTHODONTIC TERMS)

History of dental implant

• It was suggested that the first dental implant was appeared at the 16th

century before birth by Egyptian and north American

It was made from dark stone and woods

• At the area of 17th century before birth, they begun to use carved Ivory teeth.

Indications of dental implant

Indications

Severe bone loss that significantly endanger

denture retention.

Poor oral muscular coordination.

Low tolerance of mucosal tissues.

Para-functional habits leading to recurrent

soreness and denture instability.

Unrealistic prosthodontic expectation.

Active or hyper-active gag reflex precipitated by

removable denture.

Psychological inability to wear denture, even with

adequate one.

Massive bone and tissue loss following surgical

removal of tumors.

Indications

Classification of dental implant

Classification of implants according to position:

1. Endodontic stabilizer

2. Mucosal inserts

3. Subperioteal implant

4. Transmandibular dental implants

5. Endosteal implants (transosseous)

CLASSIFICATION OF DENTAL IMPLANTS

I-Endodontic stabilizer

It is a Smooth or threaded metallic pin implant that

extends through the root canal into the periapical

bone to stabilize the mobile tooth.

Stainless steel inserts attached to the tissue surface of a removable

prosthesis that mechanically engage undercuts in surgically prepared

mucosal sites.

II-Mucosal inserts(Mucoperiosteal - implant interface)

1

• Its framework is made of cobalt chromium molybdenum based

alloy resting on the alveolar bone beneath the periosteum, with

abutment posts and intraoral bars to attach a prosthesis

III- Subperiosteal implants

Indication

When there is not enough bone in which to place an

endosteal implant.

Severely atrophied mandible.

Construction

Direct bone impression (2 surgical exposures)

CAD-CAM generated model (only one surgical exposure)

The shape of bone for frame construction is obtained

through:

IV-Transmandibular dental implants

“staple boneplates”

Transossous dental

implant

Transosteal threaded posts which penetrate the full

thickness of the mandible and pass into the oral cavity

in the parasymphysial area

The staple bone plate is used to rehabilitate the

atrophic edentulous mandible.

A plate that fits against the lower border of the mandible

at the symphysis and which has posts rising from it

- The implant is placed into the alveolar bone.

- Composed of

V- Endosteal (Endosseous) implants

1. Anchorage component (body)

a

2. Retentive component (abutment).

1- Root form endosteal implants.

a- Cylinders endosteal implant.

b- Screws or spiral post implant.

2- Blade form endosteal implant.

V- Endosteal (Endosseous) implants

Types of Endosteal (Endosseous) implants

1- Root form endosteal implants.

• Root forms can be designed as cylinders or screws or fluted orcombination. They are 3 to 6 mm in diameter and 8 to 20 mm long rootform also could be internal connection or external endosteal implants

2- Blade form endosteal implant.

• Blade form (plate form): wedge shaped or rectangular in cross section andare generally 2.5 mm wide, 8 to 15 mm deep and 15 to 30 mm long.

Designs:

V- Endosteal (Endosseous) implants

What is a dental implant?

The prosthesis: it is either single crown, fixed partial denture, over denture

or any type of restoration connected to the implant and the abutment.

The abutment: it is the core area which is connected to the implant where

the prosthetic part is attached to it.

The implant (fixture): it is the actual part that is inserted into the bone.

1- Root form endosteal implants.

AN IMPLANT IS NOT A TOOTH:

Major differences:

Implant do not decay

Implant have no dental pulps

Implant have no periodontal membrane

Implant need to osseointegrate with bone

Root forms also categorized as

• One-stage implant:

Be placed in the bone and to immediately project through mucosa into theoral cavity (and to place the cover screw or healing collar).

• The two stage:

Implant requires two surgical procedures. First it is placed in bone to thelevel of the cortical plate and the oral mucosa is sutured over it. Then leftfor a prescribed healing period (usually 3 month in the mand. and 6 to 9months in the max.) depending on the quality of bone.

In a 2nd surgery the mucosa is reflected from the superior surface of imp.and healing collar is placed and project into the oral cavity is fastened tothe implant.

Designs:1- Root form endosteal implants.

a- Cylinders which may be either tapered or baskets (hollowed with

fenestrations)

b- Screws or spiral post implant which may be either solid or

hollowed.

V- Endosseous implants1- Root form endosteal implants.

Professor Per-Ingvar Branemark(1965), Swedish orthopedic surgeon

was the first who introduce the modern dental implant. This

implant was made from titanium.

First Implant Design by Branemark

First Implant Design by Branemark

All the implant designs are

obtained by the modification

of existing designs.

John

Brunski

• In 1973 Flander a new design of endosseous implants to decrease the high

rate of failure of the old screw implants.

• The endosteal implant shaped in the approximate shape of the tooth root.

• It may be used for fixed, removable or fixed detachable prosthesis.

• It requires more than 10 mm vertical bone height, more than 6mm

buccolingual thickness, and more then 8mm mesiodistal width to avoid

undesirable complications.

V- Endosseous implants1- Root form endosteal implants.

Components of Dental Implant

Implant fixture

Abutment

Retaining screw

Abutment screw

Components of an implant restoration

Composite resin

- Screw retained implant restorations

consist of three components.

(a) implant fixture

(b) abutment

(c) restoration

- the abutment screw secures the abutment

to the fixture

- the prosthetic retention screw secures the

prosthesis to the abutment.

Gutta percha

Implant fixture

Abutment

Retaining screw

Abutment screw

Components of an implant restoration

Composite resin

Gutta percha- Can have a slot or hex head

- Access is usually covered by a

combination of gutta percha and

composite.

- Used to retain the prosthesis to the

abutment.

- Tightened to 10 ncm.

Implant fixture

Abutment

Retaining screw

Abutment screw

Components of an implant restoration

Composite resin

Gutta percha

- Can be either parallel (standard) or

conical (estheticone) in shape.

- Are secured with an abutment screw that

is tightened to 20 ncm.

(Screw retained restoration)

(Cemented restoration)

- Cera One abutment

- secured with a square head screw tightened to 32

Ncm.

Retaining options Cemented crown Vs screw retained crown

Prosthetic options Cemented crown Vs screw retained crown

Prosthetic options Cemented crown Vs screw retained crown

Prosthetic options Cemented crown Vs screw retained crown

Prosthetic options Cemented crown Vs screw retained crown

Prosthetic options Cemented crown Vs screw retained crown

Prosthetic options Cemented crown Vs screw retained crown

It is a wedge shaped implant composed of head, neck

and body with vents which develops fibro osseous

integration with bone.

The blade implant is a mean of utilizing the narrow

and/ or shallow areas of remaining alveolar bone

where dimensions do not permit the use of root form

implants. The blade implant was restorable within a

month of placement by the superstructure

2- Blade form endosteal implant.

was designed to be placed in the ramus of the mandible. to solve the problemthat existed in knife edge ridges

Ramus frame implant

Transosseous dental

implant

Sub-

periosteal

implant

Endosteal

implants

Types of Bone

In 1952,,

while conducting research into the healing patterns of bone tissue,

accidentally discovered that when pure titanium comes into direct

contact with the living bone tissue, the two literally grow together to

form a permanent biological adhesion. He named this

phenomenon “ Osseointegration"

What is Osseointegration?

Osseointegration

A direct structural and

functional connection between

living bone and the surface of

implant

Osseointegration (biologic processes)

• Blood clot formation, plasma proteins are attractedto the site accompanied by the release of cytokines andgrowth factors.

• Angiogenesis.

• Osteoprogenitor cells migration to the implantsurface.

• Cell differentiation.

• Deposition of bone at the implant surface and theosteotomy site.

Advantages of 2nd and 3rd Generations

• Increased surface area and better bone interlocking with implant surface.

• Enhanced wettability and adsorption of plasma proteins.

• Better retention of fibrin clot.

• Enhanced cell adhesion.

• Accelerated cell differentiation.

• Expression of Genes related to the calcification process is upregulated and accelerated (osteopontin,osteocalcin).

• Stronger bone – implant bond.

• As a result, osseointegration is accelerated.

CLASSIFICATION OF DENTAL IMPLANTS ACCORDING TO

THE MATERIAL INTO:

Ceramics.

Polymers, or

Carbons which decreases the induced stresses in bone, but of lower

strength quality.

I- Non metallic implants,

II- Metallic implants,

High strength metals. It is one of the most suitable types.

CLASSIFICATION OF DENTAL IMPLANTS ACCORDING TO

THE MATERIAL INTO:II- Metallic implants,

a- Pure titanium:

The titanium oxide surface was responsible for the formation of the direct

bone- implant interface.

b- Titanium alloy:

The titanium alloys exist in three forms: alpha, beta and alpha beta phases

and they all originate when pure titanium is heated and mixed with

aluminium and vanadium.

• Made from Ti-Alloy.

• Outer layer is titanium oxide. Which may be pure titanium surface or with

other option such as TPS titanium plasma-sprayed surface, Ti. coated with

HA hydroxiapetite or porous ceramic substitute or (tri ca-ph)

• GRIT Blasted or acid etched to roughen the surface and increase the area for

bone contact.

Material:

a- Sand blasted surface.

b- Titanium Plasma Sprayed surface (TPS), it has satisfactory results

regarding the osseointegration and the clinical prognosis.

c- Titanium oxide surface: coating the implants to make the inert

metal a bioactive one.

d- Hydroxyapetite coating

e- Smooth

CLASSIFICATION OF DENTAL IMPLANTS ACCORDING TO

SURFACE CHARACTERISTICS:

a- Press fit technique, Unthreaded implants, the implant site is

drilled slightly smaller than the actual implant size, where the implant is

pressed into the recipient site with slight friction.

b- Self tapping technique, Threaded implants, the threads are

used to tap its site during insertion.

c- Pre-tapping technique, in case of very dense bone, the implant

sites are better to be previously tapped using the bone tap instrument before

insertion of the threaded implant

CLASSIFICATION OF DENTAL IMPLANTS ACCORDING

TO THE INSERTION TECHNIQUE:

a- Single stage design (none submerged – transgingival): the body

of the implant is inserted into the bone with its abutment portion penetrating

through the mucoperiosteum during the healing period.

b- Two stage design: the implant body is completely embedded in bone for

complete osseointegration. Then exposed and the healing abutment is placed

for soft tissue healing before the impression is made for prosthesis

fabrication

CLASSIFICATION OF DENTAL IMPLANTS ACCORDING TO

SURGICAL STAGES:

CLASSIFICATION OF DENTAL IMPLANTS ACCORDING

TO SURGICAL STAGES:

a- Biointegration: a non mineralized zone, a pseudo-

periodontium.

b- Ligamental integration: soft tissue layer surrounding

the implant.

c- Fibrointegration.

d- Osseointegration.

a- Immediate implants, placed into a prepared extraction

socket following extraction.

b- Immediate delayed implants, placed within 6-12 weeks after

the tooth loss.

c- Delayed implants, placed after 6-12 weeks after tooth

extraction, when complete healing and bone remodeling

occur.

CLASSIFICATION OF DENTAL IMPLANTS ACCORDING

TO THE TIME OF INSTALLATION :

ACCORDING TO IMPLANT DIAMETER

•CONENTIONAL

•WIDE

•MINI IMPLANTS

a- Immediately loaded implants, an acrylic resin prosth which is

designed to be out of occlusion, placed immediately after implant

placement, specially in anterior region for esthetic purposes.

b- Delayed loading implant, done in maxillary implants after 4-6

months and in mandibular implants after 3-4 months to allow for

better Osseointegration

CLASSIFICATION OF DENTAL IMPLANTS ACCORDING TO

TIME OF INSTALLATION: TIME OF PROTHETIC LOADING

ACCORDING TO LOADING PROTOCOL

•NON FUNCTIONAL LOADING

•FUNCTIONAL LOADING

•PROGRESSIVE LOADING

What is Implant loading?

Mandible: 3-4 m

Within 48 h.

Maxilla: 6 m

2 d. – 3 m.3 – 6 m.

Within 2 weeks

Conventional vs immediate loading

A. Conventional Loading

• Branemark proposed aConventional loading following histheory of Osseointegration . He saidthat ; this is the most acceptedloading protocol that has been usedall over the world and is consideredthe safest and most convenientmethod due to its high successrates.

Effect of Micro-motion on Implants during healing phase

• Micro-movement disturbs the tissue and vascular structures necessary for initial bone healing.

• Immediately after the insertion of an implant, the bone contact area is about 10-15% even in favourable bone sites such as anterior mandible.

• If the implant is subjected to load at this point, themesenchymal stem cells differentiate to fibroblasts and a fibrous connective tissue encapsulation results.

B. Immediate and Early loading

• The rise of the 2nd and 3rd

generation of titanium implants,have lead to a dramaticimprovement in the process ofossoeintegration and bonehealing.

IS it possible?

• Several animal and human studies indicate that under the rightconditions, EARLIER LOADING OF OSSEOINTEGRATEDIMPLANTS IS POSSIBLE.

• Implants surface improvements are not enough to ensurepredictability of immediate loading.

• Immediate loading still depends on other several factors toensure it’s success

Factors affecting immediate loading ?

1. Primary Stability • The key of successful loading is the effectiveness of the primary implant

stability.

• It prevents the micro-movements of the implant during theinitial healing phase.

- Primary stability depends on two main factors

• Amount of initial bone contact

• Lateral compression of the osteotomy site

(hoop stresses)

To reach these factors, certain rules should be followed:-

Favourable bone density

minimum bone height 12mm

Bicortical stabilization Tapered implants Insertion torque up-to 45 N

2- Occlusion • Most of the damage is done by para-function.

• Clinical remounts are essential.

Anterior Single Tooth Out Of Occlusion

Posterior Quadrant Cases Anterior Guidance

One Edentulous Arch Or More Bilateral balance

3. Systemic Health • systemic diseases

• Patients receiving medications

• Smokers and grinders are not indicated too.

4. Patient Compliance • The implant is mostly vulnerable during the first 3 weeks of healing.

• Strict post operative instructions should be given to the patient.

• Placing the prosthesis out of occlusion is not enough, since the foodbolus can cause stresses on the implants.

• Tough foods should be avoided completely.

• Smoking is not allowed too.

• Para-functional habits are contra-indicated.

• Strict oral hygiene measures should be followed.

• Prophylactic Anti-biotic medication.

5. Cost and Success Rate • Immediate loading is relatively more expensive, since it requires

more skills and preparations.

• The clinician and the patient must be willing to accept 5-20% lower success rate.

6. Additional Implants • Additional implants are usually placed in immediate

implantation cases.

• This is to overcome the lower success rates and to help decrease forces falling per implant.

• This implant act as a backup plan

• Usually used for long span or edentulous cases

7. Cantilevers And Frameworks • Cantilevers should be Contraindicated .

• Rigid frameworks are recommended since they help in implant splinting and distribution of forces

8. Single Tooth Defects • Immediate loading in incisors region is predictable in

experienced hands, but has to be out of occlusion

• Cuspid region is avoided since it is difficult to control lateralforces in this area.

9. Posterior Quadrants

• Non Linear configurationsis recommended.

• Anterior guidance isrecommended.

10. Mandibular Overdentures • Current studies support the use of micro-rough implants (minimum

diameter 3mm) in immediate loading in the mandible.

• Not enough evidence support this in the maxilla.

• Splinting of implants had an effect in one year survival rate.

Advantages Of Immediate Loading

• Provides convenience and emotional benefit to the patient,by improving aesthetics and decrease number of visits.

• Eliminates the need of a removable provisional restoration.

• Improves soft tissue adaptation

• Eliminates fixture exposure due to placing a removableprosthesis over it.

Disadvantages Of Immediate Loading

• Cannot be applied to every implant patient.

• Requires more chair side time during the surgical visit dueto loading preparation.

• Higher failure risk than conventional loading since too manyfactors to adjust to.

• Requires a high degree of skill, not recommended forbeginners.

Surgical ProcedureSTEP 1: INITIAL SURGERY

STEP 2: OSSEOINTEGRATION PERIOD

STEP 3: ABUTMENT CONNECTION

STEP 4: FINAL PROSTHETIC RESTORATION

Success RatesLower jaw, front – 90 – 95%

Lower jaw, back – 85 – 90%

Upper jaw, front – 85 – 95%

Upper jaw, back – 65 – 85%

• How safe are dental implants?Assumptions:

Analyses were linear, static and assumed that materials were

elastic, isotropic and homogenous.

100% osseointegration is assumed between bone and implant.

Bone and implant are assumed to be perfectly bonded.

The stresses in the bone due to the interference fit between

implant and abutment is assumed to be relaxed after the

insertion of the abutment.

The treatment step by step

• One - stage surgery

Two - stage surgery

o Examination

o Implant installation

o Healing period

o Prosthetic procedure

o New teeth are put in place

o Examination

o Implant installation

o Abutment installation

o Healing period

o Prosthetic procedure

o New teeth are put in place

Examination

• Your dentist examines your gum, teeth and jaws.

• X-rays are taken to assess the amount of bone.

• Your medical condition will be evaluated.

The treatment step by step

The treatment step by step

One - stage surgery

Two - stage surgery

o Implants and abutments are installed at the same time and visible in the

mouth directly after surgery.

o The implants are left to “sleep” under the soft tissue. Abutments are

connected during a minor second operation.

Implant and abutment installation

Healing period

The length of the healing period is 3–6 months or shorter in

certain cases. Depends on factors such as bone quality and

implant position.

Missing teeth are replaced with temporary constructions.

The treatment step by step

Prosthetic procedure

The treatment step by step

Impressions are taken to fabricate a model of your

jaw.

A crown, bridge or denture is produced which

matches your other teeth in shape and color

Prosthetic Options in Implant Dentistry

Prosthetic Options in Implant Dentistry

- However, implant dentistry can provide a

range of additional abutment locations. .

- As a result, a number of treatment options are

available to most partially and completely

edentulous patients.

Prosthetic Options in Implant Dentistry

FIXED PROSTHESES REMOVABLE

PROSTHESES

{FP-1}

Replaces only the crown; looks like a

natural tooth.

{FP-2}

Replaces the crown and a

portion of the root

{FP-3}

Replaces missing crowns and

gingival color and portion of the edentulous

site

{RP-4}

Removable prosthesis; overdenture supported completely by implant.

{RP-5}

Removable prosthesis; overdenture supported by

soft tissue and implant.

Surgical stent

Surgical stent fabrication

Surgical stent fabrication

Surgical stent fabrication

Surgical stent fabrication

Surgical stent fabrication

Fabrication for interim prosthesis

Impression techniques

Impression techniques

Open tray impression technique:

When the implants are not sufficiently parallel to each other.

Adequate inter-arch space.

Closed tray impression technique:

When the implants are sufficiently parallel to each other

In situations with limited interarch distance and insufficient space for use ofscrew-retained impression copings

Impression techniquesOpen tray impression technique:

Impression coping

Perforated tray

Impression techniquesOpen tray impression technique:

Perforated tray

Impression techniquesOpen tray impression technique:

Impression techniquesOpen tray impression technique:

Splinting

Impression techniquesOpen tray impression technique:

Splinting

Impression techniquesOpen tray impression technique:

Impression techniquesOpen tray impression technique:

Impression techniquesOpen tray impression technique:

Impression techniquesOpen tray impression technique:

Impression techniquesOpen tray impression technique:

Impression techniquesOpen tray impression technique:

Impression techniquesOpen tray impression technique:

Impression techniquesOpen tray impression technique:

Impression techniquesOpen tray impression technique:

Impression techniquesOpen tray impression technique:

Impression techniquesOpen tray impression technique:

Implant analogue insertion Creation of soft tissue replica

Impression techniquesOpen tray impression technique:

Impression techniquesClosed tray impression technique

Sincerely :

Dr. Hussein A. Hady Hussein