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A dental implant (also known as an endosseous im- 15 year lifespans for the prosthetic teeth.[4]
plant or xture) is a surgical component that interfaces
with the bone of the jaw or skull to support a dental
prosthesis such as a crown, bridge, denture, facial prosthesis or to act as an orthodontic anchor. The basis 1 Medical uses
for modern dental implants is a biologic process called
osseointegration where materials, such as titanium, form Common uses of dental implants
an intimate bond to bone. The implant xture is rst
placed, so that it is likely to osseointegrate, then a dental
prosthetic is added. A variable amount of healing time
is required for osseointegration before either the dental
prosthetic (a tooth, bridge or denture) is attached to the
implant or an abutment is placed which will hold a dental
Individual teeth were replaced with implants where it is
prosthetic.
dicult to distinguish the real teeth from the prosthetic
Success or failure of implants depends on the health of the teeth.
person receiving it, drugs which impact the chances of osseointegration and the health of the tissues in the mouth.
The amount of stress that will be put on the implant and
xture during normal function is also evaluated. Planning the position and number of implants is key to the
long-term health of the prosthetic since biomechanical
forces created during chewing can be signicant. The position of implants is determined by the position and angle Movement in a lower denture can be decreased by
of adjacent teeth, lab simulations or by using computed implants with ball and socket retention.
tomography with CAD/CAM simulations and surgical
guides called stents. The prerequisites to long-term success of osseointegrated dental implants are healthy bone
and gingiva. Since both can atrophy after tooth extraction
pre-prosthetic procedures, such as sinus lifts or gingival
grafts, are sometimes required to recreate ideal bone and
gingiva.
The nal prosthetic can be either xed, where a person
cannot remove the denture or teeth from their mouth or
removable, where they can remove the prosthetic. In
each case an abutment is attached to the implant xture.
Where the prosthetic is xed, the crown, bridge or denture is xed to the abutment with either lag screws or
dental cement. Where the prosthetic is removable, a corresponding adapter is placed in the prosthetic so that the
two pieces can be secured together.
TECHNIQUE
2.1 Planning
Techniques used to plan implants
Technique
2.5
2.3
Bisphosphonate drugs
3
stent) prior to surgery which guides optimal positioning of
the implant. Increasingly, dentists opt to get a CT scan of
the jaws and any existing dentures, then plan the surgery
on CAD/CAM software. The stent can then be made
using stereolithography following computerized planning
of a case from the CT scan. The use of CT scanning in
complex cases also helps the surgeon identify and avoid
vital structures such as the inferior alveolar nerve and the
sinus.[17][18](p1199)
2.4
Biomechanical considerations
TECHNIQUE
2.5.2
2.6
2.5.5
height of bone.
For an implant to osseointegrate, it needs to be surrounded by a healthy quantity of bone. In order for it
to survive long-term, it needs to have a thick healthy soft
tissue (gingiva) envelope around it. It is common for either the bone or soft tissue to be so decient that the surgeon needs to reconstruct it either before or during implant placement.[18](p1084)
Immediate placement
2.6
If bone width is inadequate it can be regrown using either Three common procedures are:[26](p236)
articial or cadevaric bone pieces to act as a scaold for
natural bone to grow around.
1. The sinus lift
2. Lateral alveolar augmentation (increase in the width
of a site)
3. Vertical alveolar augmentation (increase in the
height of a site)
When a greater amount of bone is needed, it can be taken
Other, more invasive procedures, also exist for larger
from another site (commonly the back of the bottom
bone defects including mobilization of the inferior alvejaw) and transplanted to the implant site.
olar nerve to allow placement of a xture, onlay bone
grafting using the iliac crest or another large source of
bone and microvascular bone graft where the blood supply to the bone is transplanted with the source bone and
reconnected to the local blood supply.[14](pp56) The nal
decision about which bone grafting technique that is best
is based on an assessment of the degree of vertical and
The maxillary sinus can limit the amount of bone height horizontal bone loss that exists, each of which is classiin the back of the upper jaw. With a sinus lift, bone ed into mild (23 mm loss), moderate (46 mm loss) or
can be grafted under the sinus membrane increasing the severe (greater than 6 mm loss).[27](p17)
6
2.6.2
3
Soft tissue (gingiva) reconstruction
RECOVERY
3 Recovery
When the metal of an implant becomes visible a con- The steps taken to secure dental crowns on the implant xture
nective tissue graft can be used to improve the mucosal including placement of the abutment and crown
height.
The prosthetic phase begins once the implant is well inThe gingiva surrounding a tooth has a 23 mm band of tegrated (or has a reasonable assurance that it will intebright pink, very strong attached mucosa, then a darker, grate) and an abutment is in place to bring it through the
larger area of unattached mucosa that folds into the mucosa. Even in the event of early loading (less than 3
cheeks. When replacing a tooth with an implant, a band months), many practitioners will place temporary teeth
of strong, attached gingiva is needed to keep the implant until osseointegration is conrmed. The prosthetic phase
healthy in the long-term. This is especially important of restoring an implant requires an equal amount of techwith implants because the blood supply is more precar- nical expertise as the surgical because of the biomechanious in the gingiva surrounding an implant, and is theo- ical considerations, especially when multiple teeth are to
retically more susceptible to injury because of a longer at- be restored. The dentist will work to restore the vertical
tachment to the implant than on a tooth (a longer biologic dimension of occlusion, the esthetics of the smile, and
the structural integrity of the teeth to evenly distribute
width).[28](pp629633)
the forces of the implants.[6](pp241251)
When an adequate band of attached tissue is absent, it
can be recreated with a soft tissue graft. There are four Prosthetic procedures for single teeth, bridges and
xed dentures
methods that can be used to transplant soft tissue. A roll
of tissue adjacent to an implant (referred to as a palatal An abutment is selected depending on the application.
roll) can be moved towards the lip (buccal), gingiva from In many single crown and xed partial denture scenarios
the palate can be transplanted, deeper connective tissue (bridgework), custom abutments are used. An impression
from the palate can be tranplanted or, when a larger piece of the top of the implant is made with the adjacent teeth
of tissue is needed, a nger of tissue based on a blood and gingiva. A dental lab then simultaneously fabricates
vessel in the palate (called a vascularized interpositional an abutment and crown. The abutment is seated on the
periosteal-connective tissue (VIP-CT) ap) can be repo- implant, a screw passes through the abutment to secure it
sitioned to the area.[25](pp113188)
to an internal thread on the implant (lag-screw). There are
Additionally, for an implant to look esthetic, a band of variations on this, such as when the abutment and implant
full, plump gingiva is needed to ll in the space on ei- body are one piece or when a stock (prefabricated) abutther side of implant. The most common soft tissue com- ment is used. Custom abutments can be made by hand,
or zirplication is called a black-triangle, where the papilla (the as a cast metal piece or custom milled from metal
[18](p1233)
conia,
all
of
which
have
similar
success
rates.
small triangular piece of tissue between two teeth) shrinks
back and leaves a triangular void between the implant and
the adjacent teeth. Dentists can only expect 24 mm of
papilla height over the underlying bone. A black triangle
can be expected if the distance between where the teeth
touch and bone is any greater.[18](pp8184)
3.2
Maintenance
3.1
7
Alternatively, stock abutments are used to retain dentures
using a male-adapter attached to the implant and a female
adapter in the denture. Two common types of adapters
are the ball-and-socket style retainer and the button-style
adapter. These types of stock abutments allow movement
of the denture, but enough retention to improve the quality of life for denture wearers, compared to conventional
dentures.[31] Regardless of the type of adapter, the female
portion of the adapter that is housed in the denture will
require periodic replacement, however the number and
adapter type does not seem to impact patient satisfaction
with the prosthetic for various removable alternatives.[32]
3.2 Maintenance
After placement, implants need to be cleaned (similar
Prosthetic procedures for removable to natural teeth) with a Teon instrument to remove any
dentures
plaque. Because of the more precarious blood supply to
the gingiva, care should be taken with dental oss. Implants will lose bone at a rate similar to natural teeth in
the mouth (e.g. if someone suers from periodontal disease, an implant can be aected by a similar disorder)
but will otherwise last. The porcelain on crowns should
be expected to discolour, fracture or require repair approximately every ten years, although there is signicant
variation in the service life of dental crowns based on the
A cast bar of metal is secured to the implants. The com- position in the mouth, the forces being applied from opplete denture then attaches to the bar with semiprecision posing teeth and the restoration material. Where implants
are used to retain a complete denture, depending on the
attachments allowing no movement of the denture.
type of attachment, connections need to be changed or
refreshed every one to two years.[14](p76) A powered irrigator may also be useful for cleaning around implants.[33]
Overdentures
An implant is tested between 8 and 24 weeks to determine if it is integrated. There is signicant variation in
the criteria used to determine implant success, the most
commonly cited criteria at the implant level are the abFracture of abutment screws (arrow) in 3 implants sence of pain, mobility, infection, gingival bleeding, rarequired removal of the remainder of the screw and diographic lucency or peri-implant bone loss greater than
replacement.
1.5 mm.[37]
Dental implant success is related to operator skill, quality and quantity of the bone available at the site, and the
4.3
Long term
10
HISTORY
While studying bone cells in a rabbit tibia using a titanium chamber, Branemark was unable to remove it from bone. His realization that bone would adhere to titanium led to the concept of
osseointegration and the development of modern dental implants.
The original x-ray lm of the chamber embedded in the rabbit
tibia is shown (made available by Branemark).
33
History
of a young Mayan woman, with three missing incisors replaced by pieces of shell, shaped to resemble teeth. Bone
growth around two of the implants, and the formation of
calculus, indicates that they were functional as well as esthetic. The fragment is currently part of the Osteological
Collection of the Peabody Museum of Archaeology and
Ethnology at Harvard University.[5][44]
There is archeological evidence that humans have attempted to replace missing teeth with root form implants
for thousands of years. Remains from ancient China (dating 4000 years ago) have carved bamboo pegs, tapped
into the bone, to replace lost teeth, and 2000-year-old
remains from ancient Egypt have similarly shaped pegs
made of precious metals. Some Egyptian mummies were
found to have transplanted human teeth, and in other instances, teeth made of ivory.[5](p26)[44][45]
Wilson Popenoe and his wife in 1931, at a site in Honduras dating back to 600 AD, found the lower mandible
The early part of the 20th century saw a number of implants made of a variety of materials. One of the earliest
successful implants was the Greeneld implant system of
1913 (also known as the Greeneld crib or basket).[46]
Greenelds implant, an iridioplatinum implant attached
to a gold crown, showed evidence of osseointegration and
lasted for a number of years.[46] The rst use of titanium as an implantable material was by Bothe, Beaton
and Davenport in 1940, who observed how close the bone
grew to titanium screws, and the diculty they had in extracting them.[47] Bothe et al. were the rst researchers
to describe what would later be called osseointegration
(a name that would be marketed later on by Per-Ingvar
Brnemark). In 1951, Gottlieb Leventhal implanted titanium rods in rabbits.[48] Leventhals positive results led
him to believe that titanium represented the ideal metal
for surgery.[48]
11
In the 1950s research was being conducted at Cambridge
University in England on blood ow in living organisms. These workers devised a method of constructing a
chamber of titanium which was then embedded into the
soft tissue of the ears of rabbits. In 1952 the Swedish
orthopaedic surgeon, Per-Ingvar Brnemark, was interested in studying bone healing and regeneration. During
his research time at Lund University he adopted the Cambridge designed rabbit ear chamber for use in the rabbit femur. Following the study, he attempted to retrieve
these expensive chambers from the rabbits and found that
he was unable to remove them. Brnemark observed that
bone had grown into such close proximity with the titanium that it eectively adhered to the metal. Brnemark
carried out further studies into this phenomenon, using
both animal and human subjects, which all conrmed
this unique property of titanium. Leonard Linkow, in the
1950s, was one of the rst to inserted titanium and other
metal implants into the bones of the jaw. Articial teeth
were then attached to these pieces of metal.[49] In 1965
Brnemark placed his rst titanium dental implant into a
human volunteer. He began working in the mouth as it
was more accessible for continued observations and there
was a high rate of missing teeth in the general population
oered more subjects for widespread study. He termed
the clinically observed adherence of bone with titanium
as osseointegration.[28](p626)
Common types of implants
12
REFERENCES
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containing 6 percent aluminium and 4 percent vanadium
alloy) is slightly harder than CP4 and used in the industry
mostly for abutment screws and abutments.[53](pp284285) [10] Chen, Y.; Kyung, H. M.; Zhao, W. T.; Yu, W. J. (2009).
Critical factors for the success of orthodontic miniMost modern dental implants also have a textured surimplants: A systematic review. American Journal of Orface (through etching, anodic oxidation or various-media
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If C.P. titanium or a titanium alloy has more than [11] Lee, SL (2007). Applications of orthodontic mini implants.
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the bone.[55]
R.; Marx, R. E.; Mehrotra, B. (2009). American Asso-
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