Implant Surgery

From Basics to Advance

Key areas covered
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 Anatomic Considerations

Diagnosis and treatment planning Implant Planning Contraindications

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 Implant size Angulation of implants

Available bone angulation Missing teeth number Implant design Abutment number

Abutment position Implant placement Available bone Flap Raised Technique

Flapless Technique Surgical Procedure Suturing the flap Post operative Instructions
 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.

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History

The first titanium dental implant was

placed in a human volunteer in 1965,
Dr Branemark.

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”
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What is Implant
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.

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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 7
What is Implant?

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Bone Biology
 Bone Biology

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.

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 Cells and composition of Bones

Bone is composed of:

Bone forming cells Bone resorbing Nonmineral matrix Inorganic mineral

(osteoblasts & cells (osteoclasts) of collagen and salts deposited
osteocytes) non-collagenous within the matrix
proteins (osteoid)

Cells in our bones are responsible 1. Osteoblasts

for bone production, maintenance 2. Osteocytes
and modeling: 3. Osteoclasts

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 Bone matrix and Types of Bones

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.

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 Bone modeling & Remodeling

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

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Osseointegration
 Osseo Integration

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.

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 Osseo Integration

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, Excessive implant motion or poor

primary mechanical stability of the implant stability results in tensile and
implant is essential, especially in one- shear motions, stimulating a fibrous
stage surgical procedures. Primary membrane formation around the
mechanical stability consists of rigid implant and causing displacement at
fixation between the implant and the the bone-implant interface, thus
host bone cavity with no micro- inhibiting osseointegration and
motion of the implant or minimal leading to aseptic loosening and
distortional strains. failure of the implant

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 Osseo Integration

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).
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 Osseo Integration
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.

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.

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 Points to remember

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.
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Points to remember

Lekholm
and Zarb,
1985

Misch,
1988

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Implant v/s
Natural tooth
Implant v/s Natural tooth

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Implant v/s Natural tooth

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COMPONENTS

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

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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

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Abutments

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

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 Basic Abutments

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.

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 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.

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Mirus cone & Multi Unit abutment

Mirus cone abutment

• 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.

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Custom abutment types
 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.

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Custom abutments

UCLA Abutments
• Original UCLA Abutment was a plastic
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.

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UCLA TYPE ABUTMENT :wax /invest/cast

• When inter arch space is limited

• When the fixture angulation is not acceptable
• Follows contours of the soft tissue
• Conventional restorative technique

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Easy abutment

• Predefined margin
• Snap on impression cap available.

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Analog / Replicas

• Analogs allow the accurate transfer of a facsimile of the

intraoral component to a working model.
• Abutment analog
• Fixture analog

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Impression copings

• Abutment level
• Fixture level
• Linked impression copings.

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Impression copings

Open tray copings

• Pick up copings
• Square copings

Closed tray copings

• Transfer copings
• Tapered copings.

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Screw drivers

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Torque drivers

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One stage vs Two stage

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One stage vs Two stage

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Patient Selection
 Patient Selection

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???

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 Diagnosis and treatment planning

 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

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Implant Planning
Surgical Stent Preparation

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 Anatomic Considerations
• 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.

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Anatomic Considerations

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Available bone

It is the amount of bone in the edentulous area considered for implantation.

Measured in :

• Width
• Height
• Length
• Angulation
• Crown/implant ratio

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Principles of
Implant
Positioning
Principles of Implant Positioning
ALWAYS PROSTHETIC DRIVEN

X
X
X
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Principles of Implant Positioning

Four factors must be correctly addressed to achieve both optimal esthetic results
and biologic health.

Vertical Buccolingual Mesiodistal Trajectory

positioning of positioning of placement of or angle of
implant in the implant in the implant in the the implant
bone bone bone

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Vertical positioning of the implant

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.

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Crown height

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.

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Crown height

• 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

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Available bone height
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.
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Available bone height

• 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.

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Buccolingual positioning

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.

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Available bone width

• 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”

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Mesiodistal positioning

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.

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Rule of 1,2,3 & 7

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 of bone and
implant implant in implant in mm opposing tooth.
placement mm.

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Angulation
of implants
Angulation of implants

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.

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Available bone angulation

• 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.
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Available bone angulation

• Tapering 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.

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Missing teeth number & Abutment number

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.

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Missing teeth number & Abutment number

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.

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Implant
design and
Size
Implant Design

• 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.

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Implant Size
• 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.

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Available bone

• 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 - 40-90°.
Mandibular - 30-45°.

Placed With Minimal Pressure, copious irrigation and intermittent drilling.

50gms – 250 gms of load can be applied immediately.

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Surgical
Procedure
Surgical Procedure

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Flapless Technique

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Flap Raised Technique

Papilla Preserving
Single stroke Incision

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Suturing the flap

• 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

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Post operative Instructions

Antibiotics Analgesics

Oral hygiene instructions Dietary Instructions

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Recent
Advances
Implant placement

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

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Socket shield

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

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Platform switching

• Use of smaller diameter abutment on a larger

diameter implant collar
• Preserves crestal bone

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Implant materials

• Peek
• Trinia
• Biohpp
• Shape memory niti implant

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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.

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Trinia

• CAD/CAM reinforced polymer

• Used for core in non-metallic prosthetic
restorations ,including implant super structure.
• Light weight
• No firing required
• Biocompatible .

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BIOHPP

• 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.

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Shape memory abutments

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Customized 3d printed implants

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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
• Tall (16-25mm) tilted (30°-45°).-tall implants more
surface area for osseointegration
• Implants placed in pinhole manner ie,flapless

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Zygomatic ,Basal, Pterygoid Implants

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